Assessment and diagnostic

Tests Integumentary System

Review of anatomy and Physiology

Largest body organ

Composed of skin, hair , nails and glands
Divided into 2 layers epidermis (outer most)
and dermis (2nd layer), the subcutaneous tissue
is immediately under the dermis

Review of anatomy and Physiology

Epidermis thin avasular superficial layer made up of

outer dead cornified portion that serves as a
protective barrier.
Measures .05 to 0.1 mm in thickness
Nourished by blood vessels in the dermis
Replaced with new cells every 28 days
Two major cells are the melanocytes (5%) and
keratinocytes (90%)

Contd..
Melanocytes are present in the deep basal layer of
the epidermis
Contain melanin pigment color to the skin and hair
and protects the body from damaging ultraviolet rays
Sunlight and hormones stimulate the melanosome (
within the melanocyte) to produce melanin

 Keratinocytes synthesized from epidermal cells in

basal layer
As they mature ( keratinize) they move to the surface
and die to form the outer skin layer
Produce keratin a fibrous protein vital to the
protective barrier function
Upward movement of keratinocytes from the
basement membrane takes approx 4 weeks

Contd..
If new cells slough off too rapidly, the skin will appear
thin and eroded
If new cells form faster than the old cells are shed,
the skin becomes scaly and thickened
Changes in the cell cycle account for many skin
problems - Psoriasis

Review of anatomy and Physiology

2nd layer collagen bundles and supports the nerve

and vascular network (therefore assists in body
temperature and blood pressure regulation)
Thickness varies from 1- 4 mm
Has fibroblasts which produce collagen and elastin
fibers and are important in wound healing

 Subcutaneous layer primarily fat and loose

connective tissue provides insulation
It attaches itself to the underlying tissues such as
muscles and bones
Stores lipids, regulates temperature, provides shock
absorption

Skin Appendages
Hair; Nails ; Glands sebaceous and Sweat glands
(apocrine sweat glands , eccrine sweat glands,
ceruminous)
Develop from the epidermal layer and receive
nutrients, electrolytes, and fluids from the dermis
Hair and nails form from specialized keratin that
becomes hardened

Functions of the integumentary

system
Protection : Primary function of the skin
Serves as a surface barrier to external environment and
against invasion by bacteria, viruses and excessive water
loss
Fat layer insulates the body and provides protection
from trauma

Provides sensory perception for environmental

stimuli

Contd..
Controls heat regulation by responding to changes in
internal and external temperature
Helps to maintain hemostasis through fluid and
electrolyte balance
Endogenous synthesis of vitamin D ( critical to
calcium and phosphorus balance)
Absorption
Asthetic functions

Gerontologic considerations
Undergoes many physiological changes associated with
normal aging
Excessive sun exposure, systemic diseases and poor
nutrition
Loss of :
subcutaneous tissue,
substances of elastin,
collagen, and fat diminishes the protection and cushioning of
underlying tissues and organs decreases muscular tone and
results in the loss of the insulating properties of fat

Contd..
Dermal layers thin and skin becomes fragile and
transparent
Capillary loops decrease in number- contribute to
delayed wound healing
Sweat and sebeaceous glands decrease( hormonal
changes) in number and functional capacity leading
to dry and scaly skin

Contd..
Hair growth diminishes
Thinning of hair in the scalp axilla and pubic areas
Photoaging profound wrinkling, increased loss of
elasticity, mottle, pigmented areas, cutaneous
atrophy and benign or malignant lesions
Increased chances of developing bedsores on
dependent areas

Assessment
Begins at the initial contact with the patient and
continues throughout the examination
Specific areas of the skin are examined - unless the
chief complaint is that of a dermatologic nature
A general statement of the physical condition of the
skin should be recorded and specific problem should
be noted under the appropriate system
Health history questions should be asked when a skin
problem is noted

Subjective Data
Important health Information
Past health history
Will indicate previous trauma, surgery or prior disease that
involves the skin
Any changes in the skin color
Specific information related to food , pet, and drug
allergies and skin reactions to insect bites and stings
Chronic and unprotected exposure to UV light, radiation
treatments
Medications used like vitamins, corticosteroids, hormones,
antibiotics and antimetabolites etc. including OTC
medications

 Surgery or other treatments

Biopsy , skin treatments, radiation therapy

Functional health patterns

Includes various questions asked by the nurse

Health history questions

Health Perception Health management Pattern
Describe your daily hygiene practices
What skin products are you currently using?
Describe any current skin conditions , including onset,
course and treatment (if any)

Nutritional Metabolic Pattern

Describe any changes in the condition of your skin, hair ,
nails and mucus membrane
Are the conditions related to changes in your diet,
including supplemental vitamins and minerals ?
Have you noticed any changes in the way sores or
lesions heal?

Contd..
Elimination Pattern
Have you noticed changes in your skin related to
excessive sweating, dryness or swelling /

Activity exercise pattern

Do your leisure activities involve the use of any
chemicals that are potentially toxic to the skin?
What is your sun protection program?

Sleep rest pattern

Does your skin condition keep you awake or awaken you
after you have fallen asleep?

Contd..
Cognitive perceptual pattern
Do you have any unusual sensations of heat cold or
touch?
Do you have any pain associated with your skin
condition?
Do you have any joint pain?

Self perception self concept Pattern

How does your skin condition make you feel about
yourself?

Role relationship Pattern

Has your skin condition changed your relationships with
others?

Contd..
Have you changed your lifestyle because of your skin
condition?
Are there any environmental skin irritants at your
current or previous work place or home?

Sexuality Reproductive pattern

Has your skin condition changed your intimate
relationships with others?
Has your birth control method, if used , caused a skin
problem?

Coping Stress Tolerance Pattern

Are you aware of any situation or stressor that changes
your skin condition?

Contd..
Do you feel that stress plays a role in your skin condition
How do you handle stress?

Value Belief pattern

Are there any cultural beliefs that influence your
thinking or feelings about your skin condition?
Are there any treatment options that you would be
opposed to using?

Objective data
Physical examination
Primary skin lesions develop on previously unaltered
skin
Some of the common characteristics of primary and
secondary skin lesions are (given in the hand out )

General principles
Private examination room of moderate temperature
with good lighting daylight preferred
Ensure patient is comfortable and in a gown that
allows easy access to all skin areas
Be systematic and proceed from head to toe
Compare symmetric parts
Perform general inspection and then a lesion specific
examination
Use the metric system while taking measurements
Use appropriate terminology and nomenclature when
reporting or documenting

Inspection
General color and pigmentation, vascularity or
bruising and the presence of lesions or discolorations
A skin color that is normal of a particular patient can be
a sign of a pathologic condition in another patient
Color depends on the amount of melanin(brown),
carotene (yellow), oxyhaemoglobin (red) and reduced
haemoglobin ( bluish red)

Most reliable areas to assess color are the areas of

last pigmentation like sclera, conjunctiva, nailbeds,
lips and buccal mucosa
(Assessment variations given as handout )

Contd..
The skin is examined for possible problems related to
vascularity, such as areas of bruising and vascular and
purpuric lesions such as angiomas
If lesions are found then the

Color
Size
Distribution
Location
Shape - should be recorded

 Skin lesions are usually described in terms related to

the lesions configuration ( pattern in relation to other
lesions) and distribution ( arrangement of lesions
over an area of the skin) Handouts
Important to note any unusual odors colonized
lesions and overgrowth of yeast in overlapping areas
are often associated with distinctive odors

Palpation
Palpated to provide information about the temperature,
turgor and mobility , moisture and texture
Temperature back of hands
Skin should be warm without being hot
Temperature of skin increases when blood flow to dermis is
increased
Decreased body temperature occurs when in shock, chilling,
or emotional distress

Turgor and mobility

Elasticity of the skin
Gently pinching an area of skin
Loss of turgor with dehydration and aging

Contd..
Moisture of skin

Is the dampness or dryness of the skin

Increases in overlapping areas and with high humidity
Varies with environmental temperature
Skin should be intact with no flaking, scaling or cracking

Texture
Refers to the fineness or coarseness of the skin
Skin should feel smooth and firm with the surface
evenly thin in most areas

Assessment of dark skin

Genetic factors determine the skin color of the
individual vary from white to dark brown, yellow,
olive red etc.
Darker skin tone result from the reflection of the light
as it strikes the underlying skin pigment
Increased amount of melanin pigment produced by
the melanocytes result in darker skin
Increased melanin natural sun shield thus decreased
incidence of skin cancer in these individuals

Contd..
More difficult to assess than lighter skin
Assessment is more easily made in areas where the
epidermis is thin and pigmentation is lighter, such as

Lips
Mucous membrane
Palms
Nail beds

Predisposed to certain skin conditions

Pseudofolliculitis
Keloids

Diagnostic tests
Before diagnostic testing / procedure , perform an
assessment and document the findings
Nursing interventions for diagnostic procedures
includes explaining the procedure to the client and
significant others and allowing them to ask questions
and express concerns

Contd..
Explain appropriate wound care and indications of
possible side effects and complications that should be
reported
Provide instructions for follow up appointment
Documentation of diagnostic procedures and the
specific location of the lesion must be completed

Skin culture and sensitivity

Bacterial fungal and certain viral infections of the skin
can be confirmed by culture
Usually reserved for the infections that are
unresponsive to routine care and antibiotic therapy

Skin biopsy
Removal of skin tissue for histologic (cellular
microscopic) assessment or immunofluorescence
Punch , excisional , incisional
Local anesthesia is generally used, small gauge 26-30
gauge needle is recommended
Procedure is usually quick and almost painless

When is skin biopsy performed

Skin nodules
Plaques
Blisters
And other lesions to rule out malignancy and establish
an exact diagnosis

Pre-procedure
Instruct the client
Avoid using asprin and products containing asprin for 48 hrs
before the biopsy to avoid prolonged bleeding time
If client is taking anticoagulants notify the physician
Review clients medical history for liver malfunction, which
affects clotting time
If history of cardiac valve replacement prophylactic antibiotics
need to be given
Obtain informed consent
Client can eat a light meal before the procedure to avoid
syncope

Post Procedure
Cover biopsy sites with an antibiotic ointment and a
clean bandage or dry dressing unless ordered
otherwise
Non-adhesive type of dressings in clients with a
fragile or sensitive skin and clients with Latex allergy
Remind client that a follow-up assessment is
necessary and appointment should be taken for
suture removal
Inform the number of days required for getting the
results

Immunofluorescence
Designed to identify the site of an immune reaction
Combines an antigen antibody with a fluorochrome
dye
Antibodies can be made fluorescent by attaching
them to a dye
Direct immunofluorescence technique to detect
auto antibodies directed against portions of the skin

Contd..
Indirect immunofluorescence detects specific
antibodies in the patients serum

Potassium Hydroxide Examination

and Fungal culture
Confirmation of fungal infections of the skin, hair or
nails
By microscopic identification or culture of scrapings
from the area
Sites scalp , between toes , axillae , groin , under or
between the breasts, abdominal folds and nailfold

Procedure
Fine scales from edge of the site are scrapped with a
number 15 scalpel blade or the edge of a glass slide
onto a 2nd glass slide
A drop of 10% - 20% potassium hydroxide is added to
the scale, and a coverslip is placed over the specimen
Gentle pressure is applied to flatten the scales
Slide is gently heated to dissolve keratin more quickly

Contd..
The scrapings are then observed under microscope
Culture scrapings are implanted in the appropriate
culture medium
For a nail culture an altered dystrophic nail is snipped
and implanted in the medium

Patch testing
Attempt to identify substances that produce allergic
skin responses
Painless procedure
Done to differentiate between an irritant contact
dermatitis and an allergic contact dermatitis

Procedure
Small amounts of various substances or allergens are
applied to the skin using commercially prepared tapes
containing allergens
The client and significant others need to understand
that low concentration are used
Should not be performed if acute dermatitis is
present or if the client is taking substantial amounts
of oral steroids

 The tape must be worn for 48hrs without disturbing the

patches then it is removed
Interpretations are made at 48, 72 and 96 hrs and
sometimes 1 week
A specific eczematous response at the site erythema,
papules or small vesicles indicates a positive reaction and
confirms an allergic contact sensitivity
Counseling regarding allergen avoidance or the meaning of
negative result is a critical part of the test

Tzancks Smear
Used for microscopic assessment of fluids and cells
rom vesicles or bullae
An intact recently evolved vesicle top is removed and
its base scrapped with a curette
The debris is smeared onto a labeled slide and sent
for cytological examination
Presence of a multinucleated giant cell establishes a
diagnosis of viral infection such as herpes simplex or
herpes zoster infection

Wood Lights Examination

Is a special lamp ( high pressure mercury lamp) that
produces long wave UV rays which results in a
characteristic dark purple fluorescence
The color of the fluorescence is best seen in a
darkened room
Differentiates epidermal from dermal lesions and
hypo pigmented lesions from normal skin

Contd..
Lesions that still contain melanin almost disappear
under ultraviolet light
Lesions that are devoid of melanin increase the
whiteness with ultraviolet light
Reassure patient that the light is not harmful to skin
or eyes