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Integumentary Assessment Kozier Ch 30. What are the Functions of the Integumentary System?

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Presentation on theme: "Integumentary Assessment Kozier Ch 30. What are the Functions of the Integumentary System?"— Presentation transcript:

1 Integumentary Assessment Kozier Ch 30

2 What are the Functions of the Integumentary System?

3 Functional Review Protector and barrier between internal organs and external environment Barrier against foreign body intrusions –against invading bacteria and foreign matter Transmits sensation – nerve receptors –allows for feelings of temperature, pain, light touch and pressure

4 Skin Functions Regulates body temperature –regulates heat loss Helps regulate fluid balance –absorbs water –prevents excessive water & electrolyte loss. –Slow loss up to 600 ml daily by evaporation Immune Response Function –inflammatory process

5 Skin Functions Vitamin production –exposure to UV light allows for the conversion of substances necessary for synthesizing vitamin D –Necessary to prevent osteoporosis, rickets

6 Skin Assessment Visual inspection Palpation Olfactory senses Adequate lighting Remove necessary clothing while providing respect and privacy Appropriate client positions p.568

7 Visual inspection Skin color: Palor Cyanosis Jaundice Erythema Hyperpigmentation Hypopigmentation – vitiligo

8 Visible changes if the Skin Changes in skin color texture –Eczema, infections Assess the vascularity & hydration of skin Edema – swelling, pitting edema 1+ 2 mm 3+ 6 mm 2+ 4 mm 4+ 8 mm p.579 Nails – configuration, consistency, color p.579 Hair – color and distribution, aloplecia, location

9 Gerontology Considerations Watch for significant changes in aging: Decrease immunity functions Susceptibility to infections Poor nutrition Decrease collagen production – loss of subcutaneous Thinning of epidermal skin layers Increase skin problems

10 Taking more medications Excessive environmental exposure Dryness, wrinkling Uneven pigmentation Various proliferative lesions Gerontology Considerations

11 Assessing light to dark skin DescriptionLight skinDark skin Cyanosis - bluishBluish tingeAshen gray Pallor - palenessLoss of rosy glowAshen gray (drk skin) Yellowish brown (brown skin) Erythema - rednessVisible rednessDiffused; rely on palpation of warmth or edema Petechiae – small size pinpoint ecchyumosis Purplish pinpoints Usually invisible; check oral Mucosa, conjunctiva, eyelids, conjunctiva covering eyeballs.

12 Assessing light to dark skin DescriptionLight skinDark skin Jaundice - yellowYellow sclera, skin, fingernails, soles, palms, oral mucosa Reliable on sclera, hard palate, palms and soles. Ecchymosis – large diffused bluish black Purplish to yellow-green Difficult to see, check mouth or conjunctiva Brown-Tan – cortisol deficiency, increased melanin production Bronze; Tan to light brown Easily masked.

13 Assessing Lesions Vary in size, shape and cause Primary vs. Secondary Erruptions: cysts, wheals, bullous, pustules, psoriasis, eczyma, vesicles, bullae, nodules, papules Discoloration: macules (café-au-lait),

14 Disorders Affecting the Skin

15 Skin Lesions p.755 Etiology –Infections –herpes, impetigo, HIV, melanoma –Toxic chemicals: skin irritation –Physical trauma: burns, lacerations –Hereditary factors –External factors: allergens, contact dermitis –Systemic diseases: measles, lupus, nutritional deficiency

16 Skin Lesions Nursing Process Care: –Assessment: descriptions; pt. history, causative factors –Evaluation of skin – identify problem –Nursing Diagnosis –Interventions for skin care to promote healing and prevent further injury –Pain management & comfort –Infection control –Nursing evaluation & reassessment

17 Systemic Skin Diseases: Skin Disorders in Diabetes Diabetes Dermapathy – shin spots, caused by break- down of small vessels that supply the skin. Stasis Dermatitis – compromises circulation to the distal extremities due to damage of larger vessels. Problem: Injuries heal slow; increase risk for ulcerations; risk for skin infections

18 Fungal infections of the Skin Tinea Pedis (athlete’s foot) Tinea Corporis (ringworm of the body) Tinea Capitis (scalp ringworm) Tinea Cruris (ringworm of the groin) –Jock itch jock, common in diabetes. Tinea Unguium (ringworm of the nails) –onychomycosis

19 Parasitic Infections Pediculosis capitis - lice Pediculosis corporis/pubis Sarcoptes scabiei – scabies –Raised burrows found between fingers, wrists, elbows, nipples, feet, groin, gluteal folds, penis, scrotum –Poor hygienic living conditions –Increase; contagious –Secondary lesions: vesicles, papules, crust, excoriations

20 Parasitic Infections –Appear 4 wks after exposure –Elderly patients from long term facilities –Lindane, crotamiton (Eurax), permethrin

21 Nursing Diagnosis Skin Impairment r/t: GOAL: –Protect the skin –Prevent secondary infections –Promote healing

22 Skin Care Review of wound dressings

23 Wound Dressings Occlusive – airtight cover applied to skin lesions Wet –(obsolete) wet compresses applied on acute weeping, inflamed lesions Moisture-retentive –more efficient wet drsg for removing excudate: impregnated with saline, petrolatum, zinc-saline, hydrogel, antimicrobial agents. –Avoids maceration, less infections, scarring & reduces pain.

24 Wound Dressings Hydrogels – polymers with 90% water content –superficial wounds, abrasions, skin graft sites, draining venous ulcers Hydrocolloids –impermeable to water, O 2 –Remain intact during bathing. –Produce foul-smelling yellowish covering –May leave on wound for 7 days –Promote debridment & granulation tissue

25 Wound Dressings Foam – hydrophilic absorption and hydrophobic backing to prevent leaking of exudate –Nonadherent; require secondary dressing –Used over bony areas and weeping wounds Calcium alginates – absorbent fiber packing made from seaweed. –Absorbes exudate, best for macerated wounds, packing deep wounds, sinus tracking, heavy drainage - nonadherent

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