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Integumentary SystemIntegumentary SystemN210 Rachel Natividad RN, MSN, NPN210 Rachel Natividad RN, MSN, NP
Variations across the lifespan: Variations across the lifespan: InfancyInfancy
MONGOLIAN SPOT
ACROCYANOSIS
JAUNDICE
Variations across the Variations across the lifespan:lifespan:
PregnancyPregnancy AdolescenceAdolescence
Striae
Cherry AngiomaAcneLinea Nigra
Variations across the lifespan: Variations across the lifespan: ElderlyElderly
Changes R/T AgingChanges R/T AgingPhysiological Physiological
changechangePhysical FindingsPhysical Findings
↓ ↓ SQ tissueSQ tissue
Loss of collagen and Loss of collagen and elastic fiberselastic fibers
↑ ↑ Capillary fragilityCapillary fragility
↓ ↓ sweat gland activity sweat gland activity
Over exposure to sunOver exposure to sun
Loss of or inefficiency Loss of or inefficiency of melanocytes of melanocytes
Elderly: Seborrheic Elderly: Seborrheic keratoseskeratoses
Elderly: Senile Lentigines Elderly: Senile Lentigines (Liver spots )(Liver spots )
LIVER SPOTSLIVER SPOTS
WRINKLES
PURPURA
Assessing Skin TurgorAssessing Skin Turgor
AssessmentAssessment
Subjective dataSubjective data Specific Skin ComplaintSpecific Skin Complaint
Objective dataObjective data Physical assessment: Inspection and Physical assessment: Inspection and
palpationpalpation Draw picture or take photo if possibleDraw picture or take photo if possible
Skin Lesions TypesSkin Lesions Types Primary: (Initial lesions) Appear in Primary: (Initial lesions) Appear in
response to external or internal response to external or internal environment of skin.environment of skin.
Vesicle, Bulla
Primary Lesions Primary Lesions
Papule
Nodule
Tumor
Wheal
Vesicle
Bulla
Skin Lesion TypesSkin Lesion Types
Secondary Lesions: Secondary Lesions: Are a result of Are a result of trauma, trauma, chronicity, or chronicity, or infection of infection of primary lesion.primary lesion.
Secondary LesionsSecondary Lesions
Keloid
Fissure
Crust
Scale
Lichenification
Vascular LesionsVascular Lesions: Appear as red : Appear as red pigmented lesion. Could be indicative of pigmented lesion. Could be indicative of bleeding bleeding HemangiomasHemangiomas
port wine stain; strawberry mark-mature port wine stain; strawberry mark-mature hemangiomahemangioma
TelangiectasiasTelangiectasias spider angioma with pregnancy or liver spider angioma with pregnancy or liver
disease; venous lakedisease; venous lake Purpuric LesionsPurpuric Lesions
PetechiaePetechiae EcchymosesEcchymoses purpurapurpura
Skin Lesion TypesSkin Lesion Types
Vascular Lesions- Cont.Vascular Lesions- Cont.HEMANGIOMA
TELANGIECTASIA
Spider Angioma
Petechiae
Ecchymosis
Venous Lake
Vascular Lesions: Vascular Lesions: PurpuraPurpura
Bleeding disorder Minor trauma
Shapes and Shapes and ConfigurationsConfigurations
EXERCISEEXERCISEDocumentation of Skin Documentation of Skin
LesionsLesionsCOLOR COLOR
SHAPE/SHAPE/CONFIGURATIONCONFIGURATION
TYPETYPE
SIZE (L x W x D) in cmSIZE (L x W x D) in cm
DISTRIBUTION/DISTRIBUTION/ PATTERNPATTERN
EXUDATESEXUDATES AmountAmount Color/Color/
consistencyconsistency Serous (serum)Serous (serum) Serosanguinous Serosanguinous
(serum & blood)(serum & blood) Sanguinous Sanguinous
(bloody)(bloody) Purulent (pus)Purulent (pus)
Pattern Injury from Pattern Injury from Physical AbusePhysical Abuse
Lesions due to trauma or Lesions due to trauma or abuse abuse
Bruise or wound whose Bruise or wound whose shape suggests the shape suggests the instrument or weapon that instrument or weapon that caused itcaused it
Physical signs with history Physical signs with history that does not match the that does not match the severity or type of injury severity or type of injury indicates abuseindicates abuse
Scalding injury, belt Scalding injury, belt marks, bite marks, marks, bite marks, cigarette burns, deformity cigarette burns, deformity from untreated fracturefrom untreated fracture
Pattern InjuriesPattern Injuries
Pattern Injury: Pattern Injury: DistributionDistribution
Diagnostic TestsDiagnostic Tests
CultureCulture Skin BiopsiesSkin Biopsies
PunchPunch ShaveShave ExcisionalExcisional
Woods LightWoods Light DiascopyDiascopy Skin TestingSkin Testing
Parasitic InfestationsParasitic Infestations
CORPORISCAPITIS PUBIS
Infestations cont.Infestations cont.
ScabiesScabies A contagious A contagious
diseasedisease
Transmission: close Transmission: close and prolonged and prolonged contact or infected contact or infected beddingbedding
Infestations Cont.Infestations Cont.
Scabies lesion Scabies lesion distributiondistribution
Parasitic InfestationsParasitic Infestations
PediculosisPediculosis ScabiesScabies
CauseCause
Symptom & Symptom & Areas Areas affectedaffected
TreatmentTreatment
Pressure UlcersPressure Ulcers
Tissue damage caused by the skin Tissue damage caused by the skin and underlying soft tissue are and underlying soft tissue are compressed between bony compressed between bony prominence and an external surface prominence and an external surface for an extended period.for an extended period.
Pressure Ulcers Pressure Ulcers
Pressure UlcersPressure Ulcers
CAUSES (6)CAUSES (6) RISKS (4)RISKS (4) PREVENTION PREVENTION (5)(5)
Pressure UlcersPressure UlcersCAUSES CAUSES
(6)(6)RISKS (4)RISKS (4) PREVENTION PREVENTION
(5)(5)PressurePressure Mental StatusMental Status
Sensory PerceptionSensory Perception
Pressure ReliefPressure Relief
ShearingShearing ActivityActivity
MobilityMobility
Prevention of Prevention of contracturescontractures
FrictionFriction Friction ReliefFriction Relief
MoistureMoisture IncontinenceIncontinence Skin careSkin care
NutritionNutrition Nutritional Nutritional DeficienciesDeficiencies
Nutritional SuuportNutritional Suuport
CirculationCirculation
Stage 1 Pressure UlcerStage 1 Pressure Ulcer
Stage 2 Pressure UlcerStage 2 Pressure Ulcer
Stage 3 Pressure UlcerStage 3 Pressure Ulcer
Stage 4 Pressure UlcerStage 4 Pressure Ulcer
Stage 4 with NecrosisStage 4 with Necrosis
Eschar- unstageableEschar- unstageable
Ulcer AssessmentUlcer Assessment Describe ulcerDescribe ulcer
Stage Stage LocationLocation SizeSize ShapeShape
AppearanceAppearance DrainageDrainage OdorOdor StageStage
Presence of infectionPresence of infection Foul smellFoul smell Purulent drainagePurulent drainage Heat, extreme redness, Heat, extreme redness,
edemaedema
Stage that ulcer!Stage that ulcer!
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