Skin and Integumentary System

Assessment Details ● Techniques include inspection and palpation ○ Inspect for color, texture, moisture, and integrity ○ Palpate for texture, moisture, temperature, mobility, and turgor ● Voice your action, purpose, and findings ● Assess the client’s fingernails and toenails Tools ● Penlight: Good lighting for closer examination ● Gloves: Needed if any moisture, weeping, or bleeding is present ○ Standard precautions ● Ruler: Measures (in cm) unexpected findings on the skin Anatomy Skin ● Largest organ of the body ● Three layers Epidermis ● Outermost layer ● Consists of keratin (tough, fibrous protein) and melanocytes, which provide pigment Dermis ● Middle layer ● Made of collagen (connective tissue) that resists tearing of the skin and allows stretching ● Contains blood vessels, nerves, hair follicles, and sensory receptors Subcutaneous ● Bottom layer ● Consists of adipose tissue ● Aids in temperature regulation, provides a cushion, and allows it to move easily over the structures that underly skin Nails ● Clear, hard plates of keratin ● Nail Bed: The bottom layer of the nail; grows outward from the nail root Physiology Functions of the Skin and Nails ● ● ● ● ● Protect the inner body parts and organs Body temperature regulation through shivering and sweating Sensory perception of temperature, touch, and pain Excrete waste and toxic substances Produce vitamin D ○ Necessary for calcium absorption ○ Three sources: ■ Skin exposure to sunlight ■ Food ■ Dietary supplements Clinical Questions ● ● ● ● ● ● Do you have a history of allergies, rashes, or other skin problems? Do you have any changes with or have you noticed any changes with your skin or nails? Do you currently have any itching, bruising, lumps, rashes, scars, open sores, or lesions? How do you care for your skin and nails? Do you or any family member have a history of skin cancer? Do you perform a self-assessment of moles and skin lesions? Skin Color Assessment Expected Findings ● Skin color should be even and consistent with their genetic background ○ Comes from a combination of melanin (brown) pigments, carotene (yellow) pigments, and the underlying vascular bed of blood vessels (red) ○ Skin colors range from whitish-pink to light-dark brown with yellow/olive tones ● Areas of increased blood flow, such as the cheeks, chest, and genitals, often have increased reddened tones ● Clients with darker skin tones typically have lighter pigmentation on their palms/soles Expected Variations ● Generalized or localized ● Skin areas exposed to the sun tend to have increased pigmentation Hyperpigmentation ● Commonly include birthmarks, sun damage, and pregnancy changes ● Freckles, chloasma/melasma, solar lentigines (age/liver spots), cafe au lait spots, tan lines Hypopigmentation ● When melanin is somewhat decreased but not completely absent in one area ● Such as scars, stretch marks, and vitiligo ○ Vitiligo: Total lack of brown melanin pigment in patchy areas of the skin Unexpected Findings Cyanosis ● Caused by a lack of oxygen in the tissues ● Observed as a bluish skin color in lighter skin tones ● Difficult to detect in darker skin tones unless severe, in which it shows as dark undertones; observe the color of the oral mucosa and nail beds Ecchymosis (Bruises) ● ● ● ● ● Collection of blood in the dermis greater than 3 mm Typically caused by trauma Results from bleeding under the skin Appears and blotches or larger spots Change from reddish-purple to blue or yellow as they heal in lighter skin tones ○ Difficult to see in darker skin tones ● Petechiae: Indicates bleeding under the skin; appears as small purple/red spots (1-3 mm) ○ Occurs due to tiny hemorrhages (infection, trauma) in the dermal layer Purpura ● Collection of petechiae and ecchymosis covering an area ● Caused by infection or a bleeding disorder Erythema ● Caused by inflammation ● Skin appears flushed; intense red in lighter skin tones or purple tinge in darker ones Jaundice ● Yellowish skin color due to increasing levels of bilirubin, a byproduct of RBC breakdown ● Obvious in the sclera and hard palate ● In darker skin tones, it can also be noted on the palms and soles Pallor ● ● ● ● Pale or lighter skin color than usual Yellow-brown to dull gray in darker skin tones; white in lighter skin tones Can be caused by anemia or a circulatory problem Best observed by inspecting the color of the lips, mucous membranes, and nail beds Skin Texture and Moisture Expected findings ● The skin should be smooth and uniformly dry ● Oil can range from having little lubricant, causing xerosis (dry skin), to a lot of lubricant, causing seborrhea (oily skin) Expected Variations Acne ● Characterized by blackheads or whiteheads, pimples, oily skin, and possibly scarring ● Predisposes adolescents due to increased production of sweat/oil during puberty ● Can be triggered by stress Wrinkles ● As the skin ages, the epidermis thins, and skin oil production decreases ● Skin elasticity decreases, increasing wrinkling ● Cell replacement occurs at a slower rate Scars ● Fibrous tissue that forms during healing of a skin lesion or after an injury to the dermis ● Permeant change to the skin texture; can be thin or wide ● Include atrophic scars (depression in the skin due to a loss of the epidermis) and keloids ○ Results from stretching of the skin (striae or stretch marks) ● Keloid: Overgrowth of scar tissue that extends beyond the edges of the wound Unexpected Findings Velvety skin ● Extremely smooth and soft ● Can signal thyroid disease Rough, Dryness, Flakiness ● Roughness can indicate skin irritation/trauma ● If the skin is rough, dry, and flaky, it could be due to thyroid disease or dehydration Diaphoresis ● ● ● ● ● Excessive perspiration due to increased metabolic rate Occurs in fever, thyroid disorders, and increased activity Could also be due to shock, severe pain, or anxiety Heavy sweating alongside pallor could indicate heart failure Can be seen or palpated Skin Integrity Assessment Expected Findings ● Smooth and intact skin Unexpected Findings Skin Lesions ● Lesion: Either an expected variation or changes associated with trauma/disease process ● Take note of any recent skin alterations ● Document the color, height (flat or raised), shape, size (cm), location (single area or generalized), and presence of drainage (color and odor) ● Types include vascular, primary, secondary, and potentially malignant Vascular Lesions ● Results of blood leaking from blood vessels into the dermis ○ Can occur because of trauma, infections, or a disease process ○ Include petechiae, ecchymosis, and purpura Primary Lesions ● Results of a specific triggering event, which changes previously intact skin ● Flat: ○ Macule: ■ Small (< 1cm) area of pigmentation change ■ Ex. freckles, moles, measles, scarlet fever ○ Patch: ■ Larger (> 1 cm) area of pigmentation change ■ Ex. birthmark, vitiligo, hormone changes ● Raised: ○ Papule: ■ Small (< 1 cm) area ■ Ex. wart, elevated mole, skin tag ○ Plaque: ■ Larger (> 1 cm) disc-shaped area ■ Ex. psoriasis, eczema ● Raised, solid: ○ Wheal: ■ Irregular area of edema on the skin ■ Ex. insect bites, allergic reaction, hives ○ Nodule: ■ Small (< 2 cm) firm area arising from deeper in the dermis ■ Ex. melanoma, hemangioma ○ Tumor: ■ Larger (> 2 cm) firm area arising from deeper in the dermis ■ Ex. lipoma, neoplasm ● Raised, fluid-filled: ○ Vesicle: ■ Small (< 1 cm) superficial, filled with serous fluid ■ Ex. varicella (chicken pox), shingles (typically follow a nerve pathway), acute eczema ○ Bulla: ■ Larger (> 1 cm) superficial, filled with serous fluid ■ Ex. blister, medication reaction ○ Pustule: ■ Small (< 1 cm) superficial, filled with purulent fluid ■ Ex. acne, herpes simplex (cold sore) ○ Cyst: ■ Encapsulated, arising from the dermis or subcutaneous layer, filled with liquid or semi-solid fluid ■ Ex. cystic acne, sebaceous cyst Secondary Lesions ● Evolved from primary lesions ● Changes to skin surface: ○ Lichenification: ■ Thickened. elevated skin caused by long-term, intense scratching/rubbing ■ Ex. chronic skin, inflammation, psoriasis ● Debris on skin surface: ○ Crust: ■ Thickened, elevated skin caused by long-term intense scratching/rubbing ■ Ex. scab, eczema ○ Scale: ■ Excessive shedding of keratin cells from the epidermis ■ Appears as dry or greasy small flakes that are white or silvery ■ Ex. psoriasis, eczema ● Alteration to skin integrity: ○ Fissure: ■ Straight-line crack with abrupt edges; extends into the dermis ■ Ex. cheilosis (cracks in the corner of mouth), excessively dry hands/feet ○ Erosion: ■ Shallow depression only present in the epidermis layer ■ Appears moist but without bleeding ■ Ex. varicella (chicken pox), herpes simplex (cold sore) ○ Ulceration: ■ Deeper depression involving loss of epidermis and dermis ■ May bleed ■ Ex. pressure injury, poor blood flow to the extremities ○ Excoriation: ■ Loss of epidermis in linear, crusted areas ■ Ex. abrasions, scratching Potentially Malignant Lesions ● Changes to the skin surface that can indicate the presence of skin cancer ● Increased risk for clients with lighter skin tones and significant exposure to UV rays ● ABCDE method of recognizing abnormal, pigmented lesions (if two or more are present, the risk of melanoma is high): ○ Asymmetry: Compare one side of the lesion with the other; the two sides look different and are not circular/ovular ○ Border: Lesion has an irregular outline (ex. Notching, scalloping, jagged edges, or blurred/vague boundaries) ○ Color: Variation within the lesion; areas of brown, tan, black, blue, red, white, or a combination ○ Diameter: Greater than 6 mm at its largest; usually leads to biopsy by itself ○ Evolving: Changing rapidly in size, symptoms, or composition; most sensitive criteria to malignancy; might prompt an immediate biopsy ● Ugly duckling method: Recognize a mole that looks/acts different than the neighboring nevi (may itch, burn, or bleed; stands out) Intervention Needed: Pressure Injuries ● A pressure injury/ulcer forms when local circulation is impaired to underlying tissue that is squeezed tightly over a solid surface, such as a bony prominence ● Often located on the back or side of the body Risk Factors ● ● ● ● ● Limited ability to reposition Thinner skin due to aging Poor nutritional state, which affects healing Presence of moisture due to incontinence, wound drainage, or perspiration Clients being pulled up or across the bed linens, resulting in a friction injury Assessment ● Assess skin pressure and contact points with limited-mobility clients at high risk frequently (every four hours) ● Staging pressure injuries is based on the degree of tissue destruction (injuries might not progress sequentially ○ Note signs of infection and changes; presence, type of drainage, increased redness, and tissue necrosis ● Measure them with a disposable cm ruler; weekly for monitoring ○ SA estimate: largest dimension x largest dimension perpendicular to the first ○ Depth estimate is taken by inserting a sterile applicator swab into the deepest area ● Assess the client for fever, chills, and increased pain, which can indicate a bone infection Stage I ● A reddened area that does not blanch with pressure ● Texture different (firmer or softer) than surrounding tissue ● Temperature different (warmer or cooler) than surrounding tissue Stage II ● Partial loss of dermis ● Shiny or dry ulcer with pink wound bed ● May present as an intact or ruptured blister Stage III ● Full-thickness skin loss with damage or necrosis to subcutaneous tissue ● Subcutaneous fat may be visible ● Dead tissue may be present in the wound bed Stage IV ● Full-thickness skin loss resulting in exposed bones, tendons, or muscle ● Dead tissue may be present in the wound bed Interventions ● Prevent the occurrence or worsening of pressure injuries ● Inspect the skin of at-risk clients frequently daily for signs of breakdown ● Reposition clients who have decreased mobility every two hours ● Elevate the head of the bed no more than 30 degrees to prevent a shearing injury, which occurs when the client slides downward in a bed/chair ● Removes sources of excessive moisture due to incontinence, drainage, or diaphoresis ● Provide dietary supplements as indicated to improve nutritional status ● Never rub a reddened area (stage I), as it can further compromise circulation and increase tissue destruction ● Use wound care per facility guidelines ● Use a lift device or have a team lift the client when moving them up in bed Skin Temperature Checking Bilateral Temperature on Extremities 1. 2. 3. 4. Touch both of the client’s arms above the elbows with the back of your hands to compare Move the back of your hands down the arms simultaneously to the fingers Determine if the skin temperature of their arms and fingers is equal Repeat the above technique for the lower extremities; start above their anterior knees and move down their shins to their toes 5. If you detect an increase/decrease in temperature, as the client if their skin feels hot/cold Expected Findings ● The skin should be as warm as your hands and consistent across body parts Expected Variations ● If the outside environment is cold, the hands/feet could be less warm than the torso ● An extremity can be slightly cooler if immobilized in a cast or if it has a circulation issue Unexpected Findings Hyperthermia ● Elevated temperature throughout the body could indicate a fever response to an infection ● Increased temperature in a localized area can indicate an alteration, such as inflammation in a painful joint, trauma to the muscles or bones, infection, or sunburn Hypothermia ● Generalized cool body temperature is associated with poor perfusion to the entire body, such as with cardiac arrest or shock ● Localized coolness is associated with decreased blood flow to the limb, such as with a blood clot or disease that impairs blood flow Skin Mobility and Turgor Elasticity and Turgor Assessment ● Mobility: Ease of the skin to rise ● Turgor: Rise and fall of the skin (generally on the chest) ○ Determines hydration level ● Concentrate your test near the collarbone on the side of the anterior chest ● Pinch a large fold of skin between the thumb and forefinger to measure mobility ● If the skin does not return to its flat, original position, the response is known as tenting Expected Findings ● The pinched skin should rise easily and rapidly return to the flat position when released Expected Variations ● Delayed return to the original position is noted in older clients due to decreased elasticity Unexpected Findings Tenting ● ● ● ● The skin remains in an elevated position after release Skin recedes slowly downward, continuing to stand up, away from the bony skeleton Seen in clients who experienced significant weight loss This can be a sign of severe dehydration Edema ● ● ● ● Decreased mobility can indicate edema Caused by an accumulation of excess fluid in the interstitial spaces between tissues Assessed using inspection and palpation If the edema is generalized or present on both sides of the body, the problem is central ○ Ex. heart or kidney failure ● If the edema is found in only one location, it is usually due to other causes ○ Ex. infection or trauma ● An obstacle to determining skin color; fluid accumulation makes dark skin look lighter ○ Edema could mask signs of jaundice or cyanosis ● Dependent areas of the body (feet, ankles, sacral areas) are at greater risk of having remaining fluid, limiting mobility ○ This leads to further fluid pooling and predisposition to a pressure injury Pitting ● Present when pressure on the affected area leaves a visible indentation on the skin ● To palpate for pitting, use the thumb/index finger to apply pressure for 3-4 seconds on the edematous area ● If the skin remains smooth without indentation, the edema is nonpitting ● If an indentation is present, further assess the depth in mm ● Four-point scale: ○ 1+: Barely detectable indentation ○ 4+: Depression of 8 mm or more that persists for a long time ● Pitting edema is either caused by a localized problem with surrounding veins or a systemic issue with the heart, kidneys, or liver function ● Nonpitting edema is more likely caused by thyroid or lymphatic issues Nail Assessment Capillary Refill Provides information about the client’s cardiovascular and respiratory status 1. Position the client’s hands at, or near, the level of their heart 2. Grasp the nail bed of the client’s finger with your thumb and index finger 3. Press your thumb and index finger together to apply pressure to the client’s nail bed; hold the pressure until the nail bed blanches, and then release 4. Using a second hand on a watch, determine the number of seconds it takes for the nail bed to return to its normal color; capillary refill should return in two seconds or less 5. Repeat the process on the other hand Expected Findings ● The nails should be slightly curved or flat ● The base edges at the cuticle should be smooth and rounded ● Both sides of the nails, which form parallel folds, where the nails meet the surrounding skin, should be smooth and rounded ● The thickness should be uniform ● Color over the nailbed should be similar to the skin tone Expected Variations ● Nails of older adults grow slower, become thicker, and may be more difficult to trim ○ Surfaces may be brittle or composed of peeling layers ● Healed injuries to the nail bed may produce uneven ridges ● The nail color sometimes turns yellow Unexpected Findings Color Variations ● Brown with linear streaks: ○ A thin, uniform streak could be due to a mole underneath ○ If a wide band suddenly appears for someone with light skin, it could be a sign of melanoma, especially if it keeps growing or has irregular edges ● Bluish tinge: ○ Indicates cyanosis ○ This could point to serious conditions of circulation or the lungs ● Pallor: ○ Whitish nails should be due to anemia Clubbed Nails ● Bases feel spongy, and the fingertips grow wider ● The nail appears spoon-like and curves downward ● Accompanies congenital heart disease, inflammatory bowel disease, and other pulmonary diseases Jagged Nails ● Unevenness could be due to a habit of biting the nails or brittle nails Structure Variations ● Lack of blood flow in the arteries could cause the nails to thicken and become rigid ● A nutritional deficiency or acute illness could be evidenced by pits on the surface ● Severe illness, trauma, and cold exposure in a client with Raynaud disease can cause transverse grooves/lines across the nails Delayed Capillary Refill ● If the color under the nail does not return to its original state in 1-2 seconds, there might be a peripheral blood vessel or respiratory problem Health Promotion Bathing and Hygiene Practices Bathing ● Removes accumulated oil, sweat, dead skin cells, and harmful bacteria ● Promotes good circulation throughout the body ● The warmth of water dilates superficial blood vessels, increasing skin nourishment Skincare Products ● Know the ingredients used ● Alcohol-free and perfume-free products can reduce skin irritation ● Discard skincare/makeup used around the eyes 4 months after purchase ○ Prevents bacterial and fungal infections Abrasions ● Lesions are susceptible to infection, so they should be kept clean and dry ● If it is covered with a bandage, check the inner surface for drainage ○ Retained moisture provides a warm, moist site for infection development Excessive Skin Dryness ● Use alcohol-free lotions to prevent cracking, which increases the risk for infection ● Bathe less frequently or do not use soap; use mild soap if necessary and rinse thoroughly ● Drink more fluids, apply moisturizers, and wear cotton clothing Acne ● ● ● ● Keep the skin clear to prevent a secondary infection Wash the hair and skin with warm water and soap daily to remove oil Use oily cosmetics and creams sparingly Refrain from squeezing or picking at lesions Erythema ● Wash the area carefully to get rid of resident bacteria ● Use an OTC antiseptic spray, lotion, or ointment for healing Skin Protection From Sun Exposure ● Apply a broad-spectrum sunscreen 15 minutes before going outdoors ○ Should have a skin protection factor (SPF) of 30 or greater to protect against ultraviolet B (UVB) and A (UVA) rays ○ Must be reapplied after swimming or sweating ● Use wide-brimmed hats, and dress in sun-protective clothing with long sleeves ● Limit time in the sun and avoid midday sun from 10 am to 4 pm ● The risk of melanoma increases with each additional sunburn ● Regular unprotected sun/wind exposure contributes to deeper wrinkles earlier on ● The use of indoor tanning equipment increases the risk of skin cancer ○ Clients should visit a dermatologist annually to assess for malignant lesions Self-Assessment of Moles and Suspicious Lesions Skin Cancer Risk Factors ● Significant exposure to UV rays ● Heavy sun exposure, sunlamps, or tanning booths ● Personal/family history of a melanoma diagnosis ○ First-degree relatives ● 50 or more moles ● Atypical or large moles ● Red or light hair color ● Acquired brown macules on sun-exposed areas ● Freckles (inherited brown macules) ● Light eye or skin color, especially skin that freckles or burns easily ● Severe blistering sunburns in childhood ● Immunosuppression from HIV or from chemotherapy for other cancers ● Personal history of a nonmelanoma skin cancer, such as basal or squamous cell cancer Self-Assessment ● Use a well-lit room with a mirror ● Notify a healthcare provider about significant skin conditions found, including any change in the size/color of moles ● If the mole/lesion starts to bleed, has drainage, feels different, or does not heal