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Download B75 Chapter 44 - Assessing Skin Disorders
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Assessing Clients with Skin Disorders Chapter 44 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 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 Layers of the Skin Skin Color 1. Erythema reddening of the skin – fever, inflammation, sunburn, drug reaction 2. Cyanosis bluish discoloration – poor oxygenation of hemoglobin Skin Color 3. Pallor paleness of skin – shock, fear, anemia or hypoxia 4. Jaundice yellow-to-orange skin color – hepatic disorders 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 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 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?” 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 Assessments? The Physical Assessment Inspect color pallor cyanosis jaundice Inspect for lesions irregular skin, rash, hives, psoriasis scaly red patches 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 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 The Physical Assessment Rate the Edema 1+ 2+ 3+ 4+ = slight pitting = deeper pit = obvious pit, extremities are swollen = the pit remains Edema occurs in cardiovascular disease, renal failure and cirrhosis of liver Lymph Edema The Physical Assessment Hair inspect distribution and quality palpate for texture inspect the scalp for lesions Nails inspect for curvature, color and thickness 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 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 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 Skin Lesions 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 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 Vascular Skin Lesions Ecchymosis bruising - release of blood into surrounding tissues trauma, hemophilia, liver disease Hematoma similar to ecchymosis but is raised, swollen Documenting general appearance What terms describe this skin? Lymphaedema What would you document? Skin our protector for life! 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 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. 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 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 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 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
