assessment and diagnostic tests- integumentary

7/23/2019 Assessment and Diagnostic Tests- Integumentary

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Assessment and diagnostic

Tests

Integumentary System


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Largest body organ

Composed of skin, hair , nails and glands

Divided into 2 layers epidermis (outer most)

and dermis (2ndlayer), the subcutaneous tissueis immediately under the dermis

Review of anatomy and Physiology


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Epidermis thin avasular superficial layer made up of

outer dead cornified portion that serves as aprotective barrier.

Measures .05 to 0.1 mm in thickness

Nourished by blood vessels in the dermis

Replaced with new cells every 28 days

Two major cells are the melanocytes (5%) andkeratinocytes (90%)



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Melanocytes are present in the deep basal layer of

the epidermis Contain melanin pigment color to the skin and hair

and protects the body from damaging ultraviolet rays

Sunlight and hormones stimulate the melanosome (

within the melanocyte) to produce melanin

Contd..


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Keratinocytes synthesized from epidermal cells in

basal layer As they mature ( keratinize) they move to the surface

and die to form the outer skin layer

Produce keratin a fibrous protein vital to the

protective barrier function Upward movement of keratinocytes from the

basement membrane takes approx 4 weeks


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If new cells slough off too rapidly, the skin will appearthin and eroded

If new cells form faster than the old cells are shed,the skin becomes scaly and thickened

Changes in the cell cycle account for many skinproblems - Psoriasis

Contd..


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2ndlayer collagen bundles and supports the nerve

and vascular network (therefore assists in bodytemperature and blood pressure regulation)

Thickness varies from 1- 4 mm

Has fibroblasts which produce collagen and elastin

fibers and are important in wound healing



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Subcutaneous layer primarily fat and loose

connective tissue provides insulation It attaches itself to the underlying tissues such as

muscles and bones

Stores lipids, regulates temperature, provides shock

absorption


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Hair; Nails ; Glands sebaceous and Sweat glands

(apocrine sweat glands , eccrine sweat glands,ceruminous)

Develop from the epidermal layer and receivenutrients, electrolytes, and fluids from the dermis

Hair and nails form from specialized keratin thatbecomes hardened

Skin Appendages


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Protection : Primary function of the skin

Serves as a surface barrier to external environment andagainst invasion by bacteria, viruses and excessive waterloss

Fat layer insulates the body and provides protection

from trauma Provides sensory perception for environmental

stimuli

Functions of the integumentarysystem


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Controls heat regulation by responding to changes in

internal and external temperature Helps to maintain hemostasis through fluid and

electrolyte balance

Endogenous synthesis of vitamin D ( critical to

calcium and phosphorus balance) Absorption

Asthetic functions

Contd..


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Undergoes many physiological changes associated with

normal aging Excessive sun exposure, systemic diseases and poor

nutrition

Loss of : subcutaneous tissue,

substances of elastin, collagen, and fat diminishes the protection and cushioning of

underlying tissues and organs decreases muscular tone andresults in the loss of the insulating properties of fat

Gerontologic considerations


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Dermal layers thin and skin becomes fragile andtransparent

Capillary loops decrease in number- contribute todelayed wound healing

Sweat and sebeaceous glands decrease( hormonalchanges) in number and functional capacity leadingto dry and scaly skin

Contd..


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Hair growth diminishes

Thinning of hair in the scalp axilla and pubic areas

Photoaging profound wrinkling, increased loss ofelasticity, mottle, pigmented areas, cutaneousatrophy and benign or malignant lesions

Increased chances of developing bedsores ondependent areas

Contd..


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Begins at the initial contact with the patient andcontinues throughout the examination

Specific areas of the skin are examined - unless thechief complaint is that of a dermatologic nature

A general statement of the physical condition of theskin should be recorded and specific problem should

be noted under the appropriate system Health history questions should be asked when a skin

problem is noted

Assessment


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Important health Information

Past health history

Will indicate previous trauma, surgery or prior disease thatinvolves the skin

Any changes in the skin color

Specific information related to food , pet, and drugallergies and skin reactions to insect bites and stings

Chronic and unprotected exposure to UV light, radiation

treatments Medications used like vitamins, corticosteroids, hormones,

antibiotics and antimetabolites etc. including OTCmedications

Subjective Data


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Surgery or other treatments

Biopsy , skin treatments, radiation therapy

Functional health patterns Includes various questions asked by the nurse


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Health Perception Health management Pattern

Describe your daily hygiene practices

What skin products are you currently using?

Describe any current skin conditions , including onset,course and treatment (if any)

Nutritional Metabolic Pattern

Describe any changes in the condition of your skin, hair ,nails and mucus membrane

Are the conditions related to changes in your diet,including supplemental vitamins and minerals ?

Have you noticed any changes in the way sores orlesions heal?

Health history questions


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Elimination Pattern

Have you noticed changes in your skin related toexcessive sweating, dryness or swelling /

Activity exercise pattern

Do your leisure activities involve the use of anychemicals that are potentially toxic to the skin?

What is your sun protection program?

Sleep rest pattern

Does your skin condition keep you awake or awaken youafter you have fallen asleep?

Contd..


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Cognitive

perceptual pattern Do you have any unusual sensations of heat cold or

touch?

Do you have any pain associated with your skincondition?

Do you have any joint pain?

Self perception self concept Pattern

How does your skin condition make you feel aboutyourself?

Role

relationship Pattern Has your skin condition changed your relationships with

others?

Contd..


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Have you changed your lifestyle because of your skincondition?

Are there any environmental skin irritants at yourcurrent or previous work place or home?

Sexuality

Reproductive pattern Has your skin condition changed your intimate

relationships with others?

Has your birth control method, if used , caused a skinproblem?

Coping

Stress Tolerance Pattern

Are you aware of any situation or stressor that changesyour skin condition?

Contd..


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Do you feel that stress plays a role in your skin condition

How do you handle stress?

Value

Belief pattern Are there any cultural beliefs that influence your

thinking or feelings about your skin condition?

Are there any treatment options that you would be

opposed to using?

Contd..


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Physical examination

Primary skin lesions develop on previously unalteredskin

Some of the common characteristics of primary andsecondary skin lesions are (given in the hand out )

Objective data


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Private examination room of moderate temperaturewith good lighting daylight preferred

Ensure patient is comfortable and in a gown thatallows easy access to all skin areas

Be systematic and proceed from head to toe

Compare symmetric parts

Perform general inspection and then a lesion specificexamination

Use the metric system while taking measurements Use appropriate terminology and nomenclature when

reporting or documenting

General principles


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General color and pigmentation, vascularity orbruising and the presence of lesions or discolorations

A skin color that is normal of a particular patient can be

a sign of a pathologic condition in another patient Color depends on the amount of melanin(brown),

carotene (yellow), oxyhaemoglobin (red) and reducedhaemoglobin ( bluish red)

Most reliable areas to assess color are the areas of

last pigmentation like sclera, conjunctiva, nailbeds,lips and buccal mucosa

(Assessment variations given as handout )

Inspection


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The skin is examined for possible problems related tovascularity, such as areas of bruising and vascular andpurpuric lesions such as angiomas

If lesions are found then the

Color

Size

Distribution

Location

Shape - should be recorded

Contd..


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Skin lesions are usually described in terms related tothe lesions configuration ( pattern in relation to otherlesions) and distribution ( arrangement of lesionsover an area of the skin) Handouts

Important to note any unusual odors colonizedlesions and overgrowth of yeast in overlapping areasare often associated with distinctive odors


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Palpated to provide information about the temperature,turgor and mobility , moisture and texture

Temperature back of hands

Skin should be warm without being hot

Temperature of skin increases when blood flow to dermis isincreased

Decreased body temperature occurs when in shock, chilling,or emotional distress

Turgor and mobility

Elasticity of the skin

Gently pinching an area of skin

Loss of turgor with dehydration and aging

Palpation


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Moisture of skin

Is the dampness or dryness of the skin

Increases in overlapping areas and with high humidity

Varies with environmental temperature

Skin should be intact with no flaking, scaling or cracking

Texture

Refers to the fineness or coarseness of the skin

Skin should feel smooth and firm with the surfaceevenly thin in most areas

Contd..


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Genetic factors determine the skin color of theindividual vary from white to dark brown, yellow,olive red etc.

Darker skin tone result from the reflection of the lightas it strikes the underlying skin pigment

Increased amount of melanin pigment produced bythe melanocytes result in darker skin

Increased melanin natural sun shield thus decreasedincidence of skin cancer in these individuals

Assessment of dark skin


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More difficult to assess than lighter skin

Assessment is more easily made in areas where theepidermis is thin and pigmentation is lighter, such as

Lips

Mucous membrane

Palms

Nail beds

Predisposed to certain skin conditions

Pseudofolliculitis

Keloids

Contd..


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Before diagnostic testing / procedure , perform an

assessment and document the findings Nursing interventions for diagnostic procedures

includes explaining the procedure to the client andsignificant others and allowing them to ask questions

and express concerns

Diagnostic tests


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Explain appropriate wound care and indications of

possible side effects and complications that should bereported

Provide instructions for follow up appointment

Documentation of diagnostic procedures and the

specific location of the lesion must be completed

Contd..


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Bacterial fungal and certain viral infections of the skin

can be confirmed by culture Usually reserved for the infections that are

unresponsive to routine care and antibiotic therapy

Skin culture and sensitivity


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Removal of skin tissue for histologic (cellular

microscopic) assessment or immunofluorescence Punch , excisional , incisional

Local anesthesia is generally used, small gauge 26-30gauge needle is recommended

Procedure is usually quick and almost painless

Skin biopsy


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Skin nodules

Plaques Blisters

And other lesions to rule out malignancy and establishan exact diagnosis

When is skin biopsy performed


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Instruct the client

Avoid using asprin and products containing asprin for 48 hrsbefore the biopsy to avoid prolonged bleeding time

If client is taking anticoagulants notify the physician

Review clients medical history for liver malfunction, which

affects clotting time

If history of cardiac valve replacement prophylactic antibioticsneed to be given

Obtain informed consent

Client can eat a light meal before the procedure to avoidsyncope

Pre-procedure


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Cover biopsy sites with an antibiotic ointment and aclean bandage or dry dressing unless orderedotherwise

Non-adhesive type of dressings in clients with afragile or sensitive skin and clients with Latex allergy

Remind client that a follow-up assessment isnecessary and appointment should be taken for

suture removal Inform the number of days required for getting the

results

Post Procedure


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Designed to identify the site of an immune reaction

Combines an antigen antibody with a fluorochromedye

Antibodies can be made fluorescent by attachingthem to a dye

Direct immunofluorescence technique to detectauto antibodies directed against portions of the skin

Immunofluorescence


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Indirect immunofluorescence detects specific

antibodies in the patients serum

Contd..


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Confirmation of fungal infections of the skin, hair or

nails By microscopic identification or culture of scrapings

from the area

Sites scalp , between toes , axillae , groin , under or

between the breasts, abdominal folds and nailfold

Potassium Hydroxide Examinationand Fungal culture


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Fine scales from edge of the site are scrapped with a

number 15 scalpel blade or the edge of a glass slideonto a 2ndglass slide

A drop of 10% - 20% potassium hydroxide is added tothe scale, and a coverslip is placed over the specimen

Gentle pressure is applied to flatten the scales Slide is gently heated to dissolve keratin more quickly

Procedure


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The scrapings are then observed under microscope

Culture scrapings are implanted in the appropriateculture medium

For a nail culture an altered dystrophic nail is snippedand implanted in the medium

Contd..


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Attempt to identify substances that produce allergic

skin responses Painless procedure

Done to differentiate between an irritant contactdermatitis and an allergic contact dermatitis

Patch testing


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Small amounts of various substances or allergens are

applied to the skin using commercially prepared tapescontaining allergens

The client and significant others need to understandthat low concentration are used

Should not be performed if acute dermatitis ispresent or if the client is taking substantial amountsof oral steroids

Procedure


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The tape must be worn for 48hrs without disturbing the

patches then it is removed Interpretations are made at 48, 72 and 96 hrs and

sometimes 1 week

A specific eczematous response at the site erythema,papules or small vesicles indicates a positive reaction andconfirms an allergic contact sensitivity

Counseling regarding allergen avoidance or the meaning ofnegative result is a critical part of the test


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Used for microscopic assessment of fluids and cells

rom vesicles or bullae An intact recently evolved vesicle top is removed and

its base scrapped with a curette

The debris is smeared onto a labeled slide and sentfor cytological examination

Presence of a multinucleated giant cell establishes adiagnosis of viral infection such as herpes simplex orherpes zoster infection

TzancksSmear


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Is a special lamp ( high pressure mercury lamp) that

produces long wave UV rays which results in acharacteristic dark purple fluorescence

The color of the fluorescence is best seen in adarkened room

Differentiates epidermal from dermal lesions andhypo pigmented lesions from normal skin

Wood Lights Examination


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Lesions that still contain melanin almost disappear

under ultraviolet light Lesions that are devoid of melanin increase the

whiteness with ultraviolet light

Reassure patient that the light is not harmful to skin

or eyes

Contd..

assessment and diagnostic tests- integumentary

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