Health Assessment: Integumentary

Purpose of the integumentary system

* provides a barrier to protect the body from injury, penetration and loss of fluids and electrolytes
* regulates body temperature
* synthesizes vitamin D
* allows sensory perception
* provides nonverbal communication
* provides identity
* allows wound repair
* allows excretion of metabolic wastes

Purpose of the integumentary history

* Diseases of the skin
* Systemic diseases that have skin inflammation
* Physical abuse
* Risk for pressure ulcer formation
* Risk for skin cancer
* Need for health promotion education regarding skin

Common or concerning skin symptoms

Rash, non-healing lesions, moles, growths, lesions, bruising, hair loss, nail changes

OLDCART

Onset: when did it start?
Location: where is it located?
Duration: how long have you had the symptom? does it come and go?
Characteristic symptoms: describe it, has it changed
Associated manifestations: itching, discharge, bleeding
Relieving/exacerbating factors: have you used or done something to make it better?
Treatment: have you used anything to treat it?

Past history

skin diseases (melanoma, eczema, psoriasis), diabetes, PVD, allergies or food sensitivities, severe/second-degree sunburn, use of corticosteroids within the last 2 weeks, OTC medications, immunizations (chicken pox, measles)

Family history

Any family members with similar symptoms?
Does anyone in the family have allergies?
Has anyone in your family had any of the above conditions?

Lifestyle and personal habits

Bathing routines, change of product/brand, false nails/wigs, nail salon, gym use, sun exposure amount, use of sunscreen, SPF value, skin self-exams and how often, chemical or radiation exposure, hobbies, diet

Physical examination equipment

lighting, ruler, magnifying glass, gloves

Skin color

Increased pigmentation, loss of pigmentation, redness, cyanosis, pallor

Pallor

results from decreased redness in anemia and decreased blood flow occurring in arterial insufficiency or fainting

Central cyanosis

Best identified in the lips, oral mucosa, or tongue - advanced lung disease, congenital heart disease, hemoglobinopathies, cold weather, melanin in lips of darker skinned individuals

Peripheral cyanosis

Best identified in the nails, hands or feet - CHF due to decreased blood flow, pulmonary edema (may be peripheral or central), venous obstruction

Jaundice

yellow coloring that may occur in the sclera, palpebral conjunctiva, lips, hard palate, undersurface of the tongue, tympanic membrane and skin - liver disease, excessive hemolysis of RBC

Skin moisture

dryness, sweating, oiliness (acne), cracking, flaking, perspiration

Dry skin

hypothyroidism, in combination of parched cracked lips, dry mucous membranes and lack of tears - dehydration

Skin temperature

Use the backs of the hands to make this assessment; generalized warmth in fever or hyperthyroidism, coolness in hypothyroidism, local warmth in inflammation or cellulitis

Skin texture

Note roughness or smoothness; roughness in hypothyroidism, velvety in hyperthyroidism

Skin mobility and turgor

Lift a fold of skin below the clavicle, forearm or on the abdomen and note the ease with which it lifts up (mobility) and the speed with which it returns into place (turgor)

Older adults and skin turgor

Do not assess on the dorsal surface of the hand

Decreased turgor and mobility

Mobility - edema, scleroderma
Turgor - dehydration

Edema

The presence of excess fluid in the interstitial spaces, may be localized due to injury or systemic which often occurs in the dependent portions of the body (legs, feet, sacrum); may be seen with jaundice or cyanosis

Symptoms: puffy, tight, decreased mobility

Grading pitting edema

1+ - 2mm
2+ - 4mm
3+ - 6mm
4+ - 8mm

Non-pitting edema

Reflects a condition in which serum proteins have accumulated in the interstitial space with the water and coagulated - local infection, or trauma (brawny edema)

Skin lesions

Circumscribed pathologic alteration of the skin that may be classified as primary (initial) or secondary

Lesion characteristics - documentation

a. color: uniform, variegated, blanching
b. size: measure in millimeters or centimeters
c. elevation: flat, palpable, raised, pedunculated (attached to a stalk - skin tag)
d. number: solitary, multiple - how many
e. texture: palpate - smooth, fleshy, verrucous, warty, scaling (keratotic)
f. lesion type:
g. shape and pattern: round, oval, linear, clustered, annular (ring), arciform (arc), bulls-eye, geographic, serpiginous (worm-like), dermatomal, covering a skin band that corresponds to a sensory nerve root (dermatome)
h. anatomic location/distribution: generalized, localized, involve exposed areas, skin-fold areas, extensor or flexor areas, acral (peripheral) areas, involve allergens or irritants

Braden scale

Assesses risk for pressure ulcers - lower the score the the higher the risk for ulcer formation

Hair assessment

Inspection and palpation - note quantity, distribution and texture, note changes of the scalp (lesions, flaking, parasites) by separating the hair, inspect body hair (loss of pubic: hormonal, loss of leg hair: PAD)

Nail assessment

Inspect and palpate the fingernails and toenails - note clubbing

Basal cell carcinoma

Skin cancer arising in the lowest, basal level of the epidermis accounting for majority of skin cancer; rarely metastasizes

Squamous cell carcinoma

Skin cancer arising in the upper layer of the epidermis; usually crusty, scaly, red, inflamed or ulcerated; can metastasize

Melanoma

Skin cancer arising from the pigment-producing melanocytes in the epidermis that give the skin its color; lethal due to high rate of metastasis

Risk factors for Melanoma

* personal/family history
* atypical or dysplastic moles (change in color or size)
* male gender
* 50 or more common moles
* red or light hair
* light eye or skin color, especially skin with freckles or skin that burns easy
* actinic keratoses, solar lentigines (brown macules on sun exposed areas)
* severe blistering sunburns in childhood
* immunosuppression (HIV, chemo)

Actinic keratosis

Prevention of skin cancer

* avoiding ultraviolet radiation and tanning beds
* regular use of sunscreen
* screening and self-evaluation

Inspecting moles

A: asymmetry of one side of the mole
B: irregular borders (ragged, notched, blurred)
C: change in color
D: diameter >6mm or different from others
E: evolving rapidly in size, symptoms, or morphology

Detecting aggressive nodular melanomas:
E: elevated
F: firm
G: growing

Cyanosis

Bluish color

Erythema

Red hue, increased blood flow

Picture: "slapped cheeks" or erythema infectiosum (fifth disease)

Carotenemia

Yellow hue seen in patients with a high dietary intake of carrots or other yellow fruits/veggies - not harmful but requires assessment of diet

Jaundice

Yellow hue seen mostly in the sclera or mucous membranes

Causes: liver disease, hemolysis of red blood cells

Cafe Au Lait spot

Slightly but uniformly pigmented macule or patch with a somewhat irregular border

Benign: 0.5-1.5 cm
Neurofibromatosis: six or more spots measuring >1.5 cm

Vitiligo

Depigmented macules appear on the face, hands, feet, extensor surfaces, and other regions and may coalesce into extensive areas that lack melanin

Brown pigmentation is the normal skin color whereas the pale areas are vitiligo

Tinea Versicolor

Common superficial fungal infection of the skin causing hypopigmentation, slightly scaly macules on the trunk, neck, and upper arms (short-sleeved distribution)

Note: they are easier to see in darker skinned individuals, in lighter skinned individuals they may be seen as reddish or tan instead of pale

Acanthosis Nigricans

A skin condition characterized by areas of dark, velvety discoloration of the body folds and creases, may result in thickened areas of the skin - usually seen in groin, neck and armpits

Associations: obesity, diabetes

Linear

lesions that appear in a straight line

Examples: lineal epidermal nervus

Clustered

lesions that are grouped

Example: Herpes simplex

Annular or arciform

circular shaped lesions

Example: annular lesion of tinea faciale (ringworm)

Target

lesions that have a bulls-eye appearance

example: lyme disease

Geographic

areas of one color, with variably scalloped borders interface with another color

example: Mycosis fungoides

Serpiginous

lesions appear to creep from one part to another - margin appears wavy

example: Tinea corporis

Confluent

lesions that run together

example: small-vessel vasculitis

Zosteriform

lesions that follow a nerve dermatome

example: herpes zoster or shingles

Macule

Primary

non-palpable lesion with local changes in color

<1.0 cm

examples: hemangioma, vitiligo

Patch

Primary

non-palpable lesions with local changes in color

> or = to 1.0 cm

example: cafe au lait spot

Plaque

Primary

Palpable elevated superficial lesion that is 1.0 cm or larger often formed by coalescence of papules

example: psoriasis

Papule

Primary

Less than 1.0 cm palpable elevated lesion

example: psoriasis

Nodule

Primary

Marble like palpable lesion larger than 0.5 cm, often deeper and firmer than a papule

example: dermatofibroma

Cyst

Primary

nodule filled elevated lesion with expressible material - either liquid or semisolid

example: epidermal inclusion cyst

Wheal

Primary

An irregular, often reddish or deeper brown superficial area of localized skin edema

example: uticaria

Vesicle

Primary

Palpable, serous fluid-filled lesion measuring less than 1.0 cm

example: herpes simplex

Bulla

Primary

Palpable, serous fluid-filled lesion measuring greater than 1.0 cm

example: insect bite

Pustule

Primary

Palpable, elevated pus-filled lesion

example: acne, small pox

Burrow

Primary skin lesion

A minute, slightly raised tunnel in the epidermis, commonly found on the finger webs and on the sides of the fingers - short lineal or curved line and may end in a tiny vesicle

example: scabies (magnifying lens can identify the burrow of the mite that causes scabies)

Scales

secondary skin lesion

flakes of dead exfoliated epidermis - color may be white, gray or silver, texture may be fine or thick

example: Ichthyosis vulgaris, dry skin

Crust

secondary skin lesion

The dried residue of skin exudates such as serum, pus, or blood that can be red-brown, orange or yellow

Lichenification

Secondary

Visible and palpable thickening of the epidermis and roughening of the skin with increased visibility of the normal skin furrows

example: neurodermatitis

Scars

Secondary

flat connective tissue left after an injury or disease heals - can be red or purple initially but older scales may appear faded silver or white

Keloid

Secondary

Hypertrophic scarring that extends beyond the borders of the initiating injury

will come back if you attempt to remove

Erosion

Secondary

non-scarring wearing away of the superficial epidermis; surface is moist but does not bleed

example: aphthous stomatitis

Excoriation

Secondary

linear or punctuate erosions caused by scratching

example: cat scratch

Fissure

secondary

a linear crack in the skin, often resulting from excessive dryness

example: Athlete's foot

Ulcer

Secondary

a deeper loss of epidermis and dermis; may bleed or scar

example: stasis ulcer of venous insufficiency

Petechia/Purpura

Deep red or purple purpuric lesions; 1-3mm

Can be round, irregular or flat

Ecchymosis

Purple or purplish in color purpuric lesions that fade into green, yellow or brown with time; larger than petichiae but vary in size (>3mm)

Bruise

Stage 1 pressure ulcer

Pressure-related alteration of intact skin

Stage 2 pressure ulcer

Partial-thickness skin loss involving the epidermis, dermis or both

Stage 3 pressure ulcer

Full-thickness skin loss with damage to or necrosis of the subcutaneous tissue that may extend to but not through the muscle

Stage 4 pressure ulcer

Full-thickness skin loss with destruction, tissue necrosis or damage to underlying muscle, bone or supporting structures

Suspected deep tissue injury

Unstageable pressure ulcer

Pressure ulcer that includes eschar, where the wound bed is not visible

Atrophic scar

pitting appearance; underlying structures are lost