Integumentary AssessmentSkin, Hair, and Nails

Georgia Baptist College of NursingOf Mercer University

Mary M. Hudgins, RN, MSNInstructor

What Are We Talking About? Structure and Function

Subjective Data Health History Questions

Objective Data The Physical Exam

Abnormal Findings

Structure and Function

Skin – _________ Layers Epidermis▫ Stratum Germinativum (basal skin

layer)– Forms _____ ______ _______

▫ Stratum Corneum (horny cell layer)– Constantly being _______

▫ Derivation of skin __________– Melanin– Carotene– Vascular bed

Skin Layers Continued….

Dermis Connective tissue (__________) __________ tissue

Subcutaneous Layer

Epidermal Appendages

Hair __________ hair ____________ hair

Sebaceous Glands Sweat glands

__________ glands ___________ glands

Nails

Functions of the Skin

Covers the _______ ________ of body

Protects body from trauma and ________

Prevents the loss of ________ and ______________

Senses __________, pain, ________, pressure

Functions of the Skin

Regulates body _______________ through

_______ ____________ and evaporation

Synthesizes Vitamin ______

Promotes wound ___________ –

_____ _________

Relationship of Skin, Hair, and Nails with Body Systems

Respiratory Cardiovascular Gastrointestinal Neurological Endocrine Immune

Chief Complaints

Rash or skin _________ Changes in skin _________ Itching (________) Changes in Hair Changes in Nail

Subjective DataHealth History Questions

Hx of skin disease? Any known _________? Family History? Birthmarks or ___________?

Change in skin ______ or _________? Generalized or localized?

Change in ______? ________that does not heal?

Health History Cont.

Excessive dryness or moisture? Itching? Excessive ________? Rash or __________? _____________

Health History: Hair

Loss or gain? Changes in _______ or appearance? Associated with other symptoms? Unusual ___________? Serious illness?

Health History:Nails

Change in nails?

What is ________ condition?

Do you ______ or ________ nails?

__________ nails, tips, chemicals

Health History

Environmental/Occupational _________?

_______ exposure? Recent __________ __________? Exposure to plants/_________ Self-care

Objective DataThe Physical Exam

Equipment Strong Direct Lighting Small Centimeter Ruler Penlight Gloves Magnifying Glass

Physical Exam

Inspection General to ____________ Drape Begin with exposed areas Compare▫ __________ ____________ areas▫ _________ exposed/non-exposed areas

Cleanliness

Palpation

___________ areas first Compare ___________ for general differences/

Moisture Back of hand (dorsa)

Skin Assessment

Color General Pigmentation

Widespread __________ Change– Pallor– __________– Cyanosis– ___________

Skin AssessmentInspect and Palpate

Temperature ___________ ____________

Moisture ___________ ______________

Skin AssessmentInspect and Palpate

Texture

___________

Edema

Mobility and __________

Vascularity or _____________

Skin LesionsInspect and Palpate

Color _________ Pattern or ________ Size________ and distribution Exudate

Promoting Health and Self-Care

Teach skin self-examination

ABCDE rule – Abnormal Characteristics

A______________B_______ ___________C________ ____________D__________ ____________E_________ and _____________

Hair AssessmentInspect and Palpate

Color ________ Distribution _________

Nail AssessmentInspect and Palpate

Shape and contour ______ ________

Consistency

Color ________ ________

Special Assessment Considerations

Infants Adolescents Pregnant Female Aging Adults Cultural/Ethnicity

Abnormal FindingsShapes/Configurations of

Lesions Annular or circular Confluent Discrete Grouped Gyrate Target or Iris Linear Polycyclic Zosteriform

Confluent

Grouped Lesions

Abnormal FindingsPrimary Skin Lesions

Macule

Papule

Patch

Plaque

Nodule

Wheal

Tumor

Papule Wheal

Abnormal FindingsPrimary Skin Lesions

Urticaria

Vesicle

Cyst

Bulla

Pustule

Vesicle Pustule

Vascular Lesions

Purpura Petechiae

Abnormal Skin FindingsSecondary Lesions

Crust Scale Fissure Erosion Ulcer Excoriation Scar Atrophic Scar Lichenification Keloid

Ulcer Keloid

Malignant Skin Lesions ___________ Cell Carcinoma

_________ cell carcinoma

________________ Melanoma

Abnormal Conditions of Hair

_________ dermatitis Alopecia Pediculosis capitis Folliculitis __________

Abnormal Conditions of the Nails

________ Lines __________ Infection Clubbing

Clubbing

Documentation of Findings:Lesions

- Size - Tenderness - _____ - Blanching or - Exudate - _________of - Shape vascular lesion - _______ - Pattern ___________, distribution