Download Week 9 Integumentary System

Week 9
Assessment of
Integumentary System
(Skin)
Learning Objectives
1. Describe and list factors that affect tissue integrity.
2. Explain common physical assessment procedures used to
evaluate tissue integrity of patients across the lifespan.
3. Identify priority tissue integrity assessment findings.
4. Differentiate normal tissue integrity assessment findings
from abnormal findings.
5. Explain the process for assessment of tissue integrity.
Why is this a system?
What does it do for us?
The skin is the body's
largest
organ, covering the entire
body.
Our skin serves as a
protective shield against:
Heat
Light
Injury
Infection
Skin also:
 Regulates body temperature
 Stores water and fat
 Is a sensory organ
 Prevents water loss
 Prevents entry of bacteria
Inspection of the Skin:
Nurses conduct an
examination of the skin as
part of a routine
assessment, during regular
care, and as needed.
During a bed bath is a
good time fully assess
the patients skin.
Remove all barriers unless
contraindicated: i.e. wound
dressing
Assess and Document:
Location
 size
objective description
skin temperature
Also inspect and document
any scars reported or
noted.
A scar can indicate a healed
surgical wound or injury.
The nurse should make note
of this.
Everted:
Turned inside out; turned
outward
Everted Umbilicus:
Indicates increased pressure
in the abdomen
Palpation of the skin:
Does it feel dry, moist, rough,
smooth, bumpy, etc?
Do you feel swelling, edema,
coolness, heat, is the area warmer
than surrounding skin?
Skin should feel
warm and dry with
good color; not
pale.
Healthy Skin
Unhealthy Skin
Before and after Meth
Basic Assessment Interview
Questions
•Have you ever had any skin problems?
•If yes, was this acute and/or chronic?
•Do you have any bruises, sores, ulcers or
rashes on your body and are they slow to
heal?
•Do you have any skin pain, burning or
itching?
More Interview Questions
•Do you sunbathe or have a history of sunbathing?
•Do you work outdoors?
•How does your skin react to sun exposure?
•How do you care for your skin?
•Sensitivities or allergies?
•Tattoos and/or piercings?
Considerations as the nurse…
•Is the patient nutritionally challenged?
•Is the patient immobile?
•Does the skin appear paper-like or fragile?
Sun bathing and sunburn is
considered a risk
Sunburn Blisters and Damaged
Peeling Skin
1. Outer Skin Layer
2. Middle Skin Layer
3. Deep Skin Layer
4. First Degree Burn
5. Second Degree Burn
6. Third Degree Burn
Poison Ivy is an allergic reaction.
(Oily sap called urushiol triggers an allergic reaction
when it comes into contact with skin, resulting in an
itchy rash, which can appear within hours of exposure
or up to several days later.)
Black henna tattoo reaction;
scarring
Skin Ulcer
Venous Stasis Ulcers:
The result of venous blood collecting and
stagnating in the lower leg
(Inadequate venous return).
Necrotic Ulcer
Necrotic Toes
What causes this?
Decreased/impaired tissue perfusion.
Diabetics are at high risk for
slow healing wounds due to
vascular changes leading to
arteriosclerosis (thickening,
loss of elasticity, and
calcification of arterial walls).
Odor:
Does the wound site have an odor?
Pressure Ulcer:
(decubitus ulcer) This is
preventable by repositioning the
patient every two hours.
Varicella Rash
(Chicken Pox)
Psoriasis Rash
Dry, Scaly Skin
Age Spots:
(Liver Spots)
Age Spots:
(Liver Spots) Part of the skin’s
normal aging process. Appear
as flat gray, brown or black
spots. They vary in size and
usually appear on the face,
hands, shoulders and arms;
areas most exposed to the
sun.
Wound Types
Contusions:
Bleeding under or within layers of
skin
Abrasion:
Surface scrape, open wound
Laceration:
Tissues torn apart, open wound;
edges often jagged
Puncture or Penetrating:
Penetration of skin and
underlying tissues; open wound
Burns
Surgical Incision
Wound Measurement Guide:
Assess if the wound is getting
larger, smaller, healing, etc.
Abscess:
A swollen area within body tissue, containing an
accumulation of pus.
Candida:
Yeast/fungal infection
Skin breakdown under breasts:
Skin must be kept clean and dry.
Port-Wine Stain Birthmark
Infants and children have
sensitive skin…
• The younger the more
sensitive the skin is
• Protect from sunburn
• Protect from rashes and
irritation
Mongolian Spot Birthmark:
A dense collections of melanocytes
(not a bruise)
Older adults have sensitive skin: Skin changes
associated with aging include less elasticity,
decreased subcutaneous tissue. These factors
put them at increased risk for tears, pressure
ulcers, and skin breakdown.
Aging skin characteristics include
decreased collagen, elasticity, tone.
Elderly skin is fragile, paperthin, and tears easily.
Edema Scale
Nursing Goals Include:
• Frequent and thorough skin assessment and
interventions
• Promote wound healing
• Prevent skin breakdown and/or additional
wounds
Injury to skin, and breaks in the skin
put the patient at risk for what kinds
of problems?
• Infection at the site, also systemic
infection
• Loss of fluid
• Burns, internal injury, temperature
regulation problems (Severe sunburn:
fever and chills)
Bowel Sounds:
When bowel sounds are
hypoactive and not easily
heard, you must listen for 5
minutes to each quadrant
before deciding that bowel
sounds are absent.
True or False?
Ask the patient what time of
day they normally move their
bowels. (We attempt to work
with the time schedule they
are used to; not have them
adjust to the facility’s time
schedule.)
Constipation
Passing gas indicates bowel
motility and passing gas is
taking place.
End of Week 9