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PHYSICAL ASSESSMENT: THE INTEGUMENT
THE INTEGUMENT
Includes:SkinHairNails
THE SKIN, HAIR, AND NAILS
SKIN
Assessment of the skin invloves inspection and palpation.
In some instances, the nurse may also use the olfactory sense.
SKIN COLOR CHANGES
PALLOR
CYANOSIS
CYANOSIS
CYANOSIS
JAUNDICE
JAUNDICE
ERYTHEMA
BIRTHMARK
VITILIGO
ALBINISM
ALBINISM
EDEMA
EDEMA
SKIN LESIONS
SKIN LESIONS
Can be primary or secondary Nurses are responsible for describing
skin lesions accurately in terms of location, distribution, and configuration.
PRIMARY SKIN LESIONS
MACULES
Flat, unelevated change in color 1mm-1cm, circumscribed Ex: Freckles, measles, petechiae
PAPULE
Circumscribed, solid elevation of skin <1cm Ex: Warts, pimple, acne
PLAQUE
Larger than 1 cm Examples: Psoriasis, rubeola
NODULE/TUMOR
Solid, hard mass that extends deeper into the dermis
0.5 to 2 cm (Nodule), have circumscribed border
Ex: squamous cell ca, fibroma
VESSICLE / BULLA
A circumscribed, round or oval, thin transluscent-filled mass with fluid or blood
Size: 0.5cm Ex: Herpes simplex, early
chickenpox, burn blister
PUSTULE
WHEAL
A slightly irregular, relatively transient, superficial area of localized skin edema.
WHEAL
A slightly irregular, relatively transient, superficial area of localized skin edema.
CYST
Mass arising from the dermis or subcutaneous tissue.
SECONDARY SKIN LESIONS
ASSESSING THE SKIN
In general, we assess the client’s skin for the following:ColorLesionsMoistureTemperatureTextureMobility and turgor
ASSESSING THE SKIN ACROSS THE LIFESPAN
INFANTS
INFANTS
Physiologic Vs. Pathologic Jaundice
INFANTS
Milia
INFANTS
Vernix Caseosa
INFANTS
Lanugo
INFANTS
INFANTS
Diaper Dermatitis
INFANTS
CHILDREN
CHILDREN
Children have minor skin lesions on arms and legs due to high-activity level
Secondary skin lesion may occur frequently
CHILDREN
ELDERS
ELDERS
Changes in white skin occur at an earlier age than in black skin
Common skin findings:WrinklesThin and dry skinPoor skin turgorSenile lentigines
ELDERS
ELDERS
ELDERS
ELDERS
ELDERS
ELDERS
ELDERS
THE NAILS AND HAIR
THE HAIR
The hair, together with the nails, is differentiated tissue but continuous extension of the skin.
Hair is generally distributed over the body except in some areas
The amount and texture varies with age, sex, race, and body part
Types:VellusTerminal hair
NORMAL HAIR
ABNORMAL HAIR FINDINGS
ABNORMAL HAIR FINDINGS
HAIR ASSESSMENT PROCEDURES 1. Introduce self 2. Perform hand hygiene 3. Provide privacy 4. Inquire if the patient has any
history of using hair cosmetics and presence of any disease
HAIR ASSESSMENT PROCEDURES 5. Inspect the hair for the ff:
EvennessThickness/thinnessTexture and oilinessInfections or infestationsAmount of body hair
Document findings
THE NAILS
THE NAILS
Nails are inspected for:Nail plate shapeAngleTextureNail bed colorIntactness of surrounding tissues
THE NORMAL NAIL
ABNORMAL NAIL FINDINGS
ABNORMAL NAIL FINDINGS
ABNORMAL NAIL FINDINGS
ABNORMAL NAIL FINDINGS
ABNORMAL NAIL FINDINGS
ABNORMAL NAIL FINDINGS
ABNORMAL NAIL FINDINGS
ABNORMAL NAIL FINDINGS
BLANCH TEST
BLANCH TEST (CAPILLARY REFILL TEST)
BLANCH TEST: AN EARLY INDICATOR OF SHOCK?
ASSESSMENT OF THE NAILS
1. Introduce self 2. Observe infection control
procedures 3. Provide for privacy 4. Inquire for presence of certain
diseases
ASSESSMENT OF THE NAILS
5. Inspect nails for:Nail plate shapeTextureColorSurrounding tissue
6. Perform blanch test 7. Document findings
What are the Lifespan Considerations when assessing the nails?
THANK YOU!
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