Ch. 24 Assessment of the Integumentary System

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Chapter 24: Assessment of the Integumentary System

Conceptual Focus

• Health Promotion

• Tissue Integrity

Learning Outcomes

1. Describe the structures and functions of the integumentary system.

2. Identify age-related changes and their impact on assessment findings.

3. Obtain significant subjective and objective data during assessment.

4. Differentiate between primary and secondary skin lesions.

5. Perform a thorough physical skin assessment using correct techniques.

6. Compare assessment differences in light- and dark-skinned individuals.

7. Recognize normal vs. abnormal skin findings.

8. Describe diagnostic studies related to skin conditions and nurse responsibilities.

I. Overview of the Integumentary System

A. Structures of the Integumentary System

• Largest organ system in the body, composed of:

  • Skin

  • Hair

  • Nails

  • Glands (Sebaceous, Sweat - Eccrine & Apocrine)

1. Layers of the Skin

Epidermis (Outer Layer)

• Thin, avascular layer

• Composed of keratinized epithelial cells

• Key cell types:

  • Keratinocytes (90%) – Produces keratin, forming a protective barrier

  • Melanocytes – Produces melanin (pigmentation and UV protection)

  • Langerhans’ Cells – Immune function (antigen recognition)

  • Merkel Cells – Responsible for light touch sensation

• Epidermis Regeneration Cycle

  • New cells take 14 days to reach the surface

  • Cells stay at the surface for 14 more days before shedding

  • Complete renewal every 28 days

Dermis (Middle Layer)

• Connective tissue layer (Collagen & Elastin)

• Highly vascular (contains blood vessels and lymphatics)

• Contains:

  • Nerves (pain, temperature, touch receptors)

  • Hair follicles & sebaceous glands

  • Immune cells (Mast cells, Macrophages)

• Collagen production by fibroblasts is essential for wound healing.

Subcutaneous Tissue (Hypodermis)

• Fat & connective tissue layer

• Functions:

  • Insulation & temperature regulation

  • Shock absorption

  • Energy storage

• Thickness varies with age, sex, and nutrition.

B. Appendages of the Skin

1. Hair

• Functions: Protection & sensation

• Hair Growth Cycle:

  • Anagen (growth phase)

  • Catagen (transitional phase)

  • Telogen (resting phase)

• Alopecia (hair loss) can be due to genetics, illness, stress, or medication.

2. Nails

• Composed of keratin

• Lunula (white crescent) – Site of nail growth

• Normal angle: 160 degrees

• Clubbing (>180 degrees) may indicate chronic hypoxia (COPD, heart disease)

3. Glands

Sebaceous Glands (Oil Glands)

• Secretes sebum (keeps skin moisturized)

• Located everywhere except palms & soles

• Overproduction → Acne

Sweat Glands

• Eccrine: Covers most of body, controls temperature regulation

• Apocrine: Found in axilla, groin, areola – active during puberty

II. Functions of the Integumentary System

III. Age-Related Changes in the Skin

💡 Nursing Considerations:

• Moisturize dry skin

• Encourage sun protection

• Assess for pressure injuries

IV. Skin Assessment

A. Subjective Data

• History of Skin Conditions (Psoriasis, eczema, melanoma)

• Medications (Steroids, chemotherapy, antibiotics)

• Allergies (Food, drug, environmental)

• Sun Exposure History (Tanning, burns, sunscreen use)

• Nutritional Status (Vitamin A, C, E, Protein for wound healing)

B. Objective Data

1. Inspection

• Color Changes: Cyanosis, jaundice, erythema, pallor

• Lesions:

  • Primary Lesions (Freckles, papules, pustules)

  • Secondary Lesions (Ulcers, scars, fissures)

• Hair/Nails: Changes may indicate systemic disease

2. Palpation

• Skin Temperature (Hot = infection, Cold = poor circulation)

• Turgor Test (Dehydration causes tenting)

• Capillary Refill (>3 seconds = poor perfusion)

C. Differences in Light vs. Dark Skin

• Dark skin is more prone to:

  • Keloids (thick scars)

  • Vitiligo (patchy pigment loss)

  • Traction Alopecia (hair loss from styling tension)

• Best areas to check for color changes in dark skin:

  • Mucous membranes, palms, soles, sclera

V. Common Skin Conditions

VI. Diagnostic Tests for Skin Disorders

VII. NCLEX-Style Practice Questions

1⃣ The primary function of the skin is:
b) Protection ✅

2⃣ Which are age-related changes affecting hair/nails?
b) Scaly scalp ✅
d) Thick, brittle nails ✅

3⃣ Which skin lesion is firm, edematous, and irregularly shaped?
a) Wheal ✅

Summary: Assessment of the Integumentary System

I. General Principles of Skin Assessment

• Skin assessment starts with first patient contact and continues throughout the exam.

• Observing skin, hair, and nails is crucial, even when examining other body systems.

• If a patient’s chief complaint is skin-related, perform a focused skin assessment.

II. Normal Findings in a Physical Assessment (Table 24.2)

• Skin: Even pigmentation, warm, no lesions, good turgor.

• Nails: Pink, oval, adhered to nail bed, normal 160-degree angle.

• Hair: Shiny, full, appropriate for age/gender, no flaking.

III. Case Study: 74-Year-Old Patient with Facial Lesions

• Patient reports new “spots” on her face and is concerned about skin cancer.

• Assessment considerations:

  1. Type of assessment needed? (Comprehensive vs. Focused vs. Emergency)

  2. Possible causes of facial lesions? (Aging, sun damage, melanoma, etc.)

  3. Questions to ask? (History of sun exposure, changes in lesion appearance, family history of skin cancer)

IV. Subjective Data Collection

A. Health History:

• Previous skin diseases, trauma, or surgery (e.g., melanoma, psoriasis, eczema)

• Chronic conditions that affect skin (e.g., diabetes, liver disease, anemia, cardiovascular disorders)

• Sun exposure history (e.g., sunscreen use, tanning beds, history of sunburns)

• History of allergic reactions (e.g., medications, food, insect bites)

B. Medication History:

• Many medications cause skin-related side effects:

  • Steroids & Hormones – May cause skin thinning, acne

  • Antibiotics – Can cause photosensitivity or rashes

  • Chemotherapy & Immunosuppressants – Affect wound healing, pigmentation

C. Functional Health Patterns (Table 24.3):

• Daily hygiene & skincare products used

• Dietary history (nutrition affects wound healing)

• Changes in wound healing or weight loss

• Exposure to workplace chemicals, excessive sun, or irritants

• Pain, sensory perception issues (e.g., numbness, tingling)

• Psychosocial impact (self-esteem, relationships)

V. Common Systemic Diseases with Skin Manifestations (Table 24.4)

VI. Skin Cancer Risk Factors (Box 24.1)

• Primary risk: UV exposure damages DNA, leading to skin cancer.

• Genetic predisposition: Family history of melanoma increases risk.

• Fair-skinned individuals (blonde/red hair, light eyes) have higher risk.

VII. Comprehensive Skin Examination

1. Inspection

   • Skin color changes: Cyanosis (blue), pallor, jaundice (yellow), erythema (redness)

   • Lesions: Assess for size, shape, distribution, texture, and color

   • Vascular changes: Bruising, petechiae, purpura (non-blanching lesions)

   • Body art: Check for tattoos, piercings, needle marks that may indicate infection risks.

2. Palpation

   • Temperature: Increased = infection/inflammation, Decreased = poor circulation

   • Moisture: Dehydration → dry skin, excessive moisture → sweating disorders

   • Turgor: Pinch skin to assess hydration status (tenting = dehydration)

   • Edema: Swelling indicates fluid retention or poor circulation

3. Assessment in Dark-Skinned Patients (Table 24.9)

   • Cyanosis: Hard to detect—look at mucous membranes & nail beds

   • Erythema: May appear as deeper brown or purple

   • Jaundice: Best seen in sclera (not palms or soles)

   • Pressure injuries & rashes: More difficult to assess—use palpation

VIII. Common Skin Conditions & Nursing Implications

IX. Diagnostic Studies for Skin Conditions

X. Case Study Application: 74-Year-Old Patient

1. Assessment Type:

   • Focused Assessment (chief complaint: facial lesions)

2. Possible Causes of Lesions:

   • Aging spots (benign)

   • Actinic keratosis (precancerous)

   • Basal cell carcinoma (most common skin cancer)

   • Malignant melanoma (most serious skin cancer)

3. Questions to Ask:

   • Onset & Changes? (Growing, bleeding, changing color?)

   • Sun Exposure History?

   • Family History of Skin Cancer?

XI. NCLEX-Style Review Questions

1. The primary function of the skin is:
a) Insulation
b) Protection ✅
c) Sensation
d) Absorption

2. Age-related assessment findings of hair and nails include (Select all that apply):
b) Scaly scalp ✅
c) Oily scalp
d) Thick, brittle nails ✅
e) Longitudinal nail ridging ✅

3. When assessing the nutritional-metabolic pattern in relation to the skin, the nurse should ask:
a) Joint pain
b) Use of moisturizing shampoo
c) Recent changes in wound healing ✅
d) Self-care habits

4. What term describes firm, irregularly shaped, edematous skin lesions?
a) Papules
b) Wheals ✅
c) Plaques
d) Fissures

Case Study Analysis: Integumentary System Assessment

Subjective Findings of D.A.: Key Concerns

1. History of severe sunburns as a child

   • Frequent sunburns, especially in childhood, significantly increase the risk of skin cancer (including melanoma and basal cell carcinoma).

2. Newly developed facial lesions

   • D.A. reports "age spots," but some skin lesions can mimic benign age spots while being precancerous or cancerous.

3. Fear of skin cancer

   • Emotional distress indicates the need for patient education and psychological support.

4. SPF 15 sunscreen use

   • Sunscreen of SPF 15 provides only minimal protection, and the recommendation for skin cancer prevention is SPF 30 or higher.

Physical Assessment Focus

1. Inspection of Skin Lesions

   • ABCDE Rule for Melanoma:

     • A – Asymmetry (Uneven shape)

     • B – Border (Irregular or poorly defined)

     • C – Color (Varied pigmentation, dark spots)

     • D – Diameter (>6mm concerning)

     • E – Evolving (Changes in size, color, or elevation)

   • Check for Non-Melanoma Skin Cancer (Basal Cell & Squamous Cell Carcinoma)

     • Basal cell: Pearly or waxy bump, may ulcerate.

     • Squamous cell: Red, scaly patches or firm nodules.

   • Other Factors to Assess in Lesions

     • Texture (Smooth, rough, scaling, ulceration)

     • Pain, bleeding, itching

     • Growth pattern (Slow or rapid?)

2. General Skin Condition

   • Color: Pallor, jaundice, erythema, cyanosis

   • Texture & Moisture: Dryness, scaliness, cracks

   • Vascular changes: Bruising, petechiae, purpura

3. Palpation

   • Temperature: Warm (inflammation, infection) or cool (poor circulation).

   • Turgor: Check for dehydration (tenting).

   • Lesion firmness: Soft (cyst), hard (potential malignancy).

4. Nail & Hair Examination

   • Hair: Thinning, brittle, excessive loss.

   • Nails: Discoloration, ridging, thickness changes (nutritional deficiencies, systemic disease).

Diagnostic Tests for D.A.

1. Dermatoscopy (Skin Scope Examination)

   • Magnified view to identify abnormal lesion features.

2. Biopsy (Gold Standard)

   • Punch biopsy or shave biopsy to determine if the lesion is benign or malignant.

3. Wood’s Lamp (UV Light)

   • Used to detect fungal infections or hypopigmentation disorders (e.g., vitiligo).

4. Blood Tests

   • Albumin & Nutritional Panel: Rule out poor wound healing due to malnutrition.

   • CBC: Check for infection or hematologic disorders.

Priority Nursing Actions

1. Educate D.A. About Sun Protection

   • Use SPF 30+ sunscreen daily, reapply every 2 hours.

   • Wear wide-brimmed hats and protective clothing.

   • Avoid direct sun exposure between 10 AM – 4 PM.

2. Encourage Skin Self-Exams

   • Perform monthly self-checks using the ABCDE rule.

   • Report any new or changing lesions to a healthcare provider.

3. Provide Emotional Support

   • Address fear of skin cancer.

   • Explain diagnostic steps and possible treatment options.

Final Case Considerations

• Does D.A. need a dermatology referral?

  • If lesions show concerning ABCDE features, biopsy and specialist referral are necessary.

• Is there a history of family skin cancer?

  • Genetic risk increases with a first-degree relative (parent, sibling) with melanoma.

Case Study Analysis: Physical Examination & Diagnostic Studies

1. Concerning Physical Assessment Findings

The most concerning findings in D.A.’s skin assessment include:

• Multiple lesions on the face:

  • Upper right forehead: 2 × 3 mm

  • Left forehead (near hairline): 1 × 2 mm

  • Left lower cheek: 2 × 2.5 mm

• Lesion characteristics:

  • Slight erythema: Could indicate inflammation or early-stage malignancy.

  • Non-blanching with direct pressure: Suggests vascular involvement, which can be seen in melanoma, basal cell carcinoma, or squamous cell carcinoma.

  • Distinct borders: Malignant lesions (e.g., melanoma) often have irregular borders, but well-defined borders do not completely rule out skin cancer.

  • Slight elevation (cheek lesion most elevated): Elevated lesions can be benign (keratoses, nevi) or malignant (basal cell or squamous cell carcinoma).

Key Concerns

1. History of frequent sunburns as a child and ongoing sun exposure

   • Increases the risk of skin cancer, especially melanoma.

2. Presence of multiple lesions with erythema and non-blanching characteristics

   • This warrants further investigation for possible malignancy.

3. Distinct lesions on the face with slight elevation

   • Could be early-stage basal cell carcinoma, squamous cell carcinoma, or actinic keratosis (a precancerous lesion).

2. Recommended Diagnostic Studies

Given the findings, D.A. should undergo diagnostic testing to determine if the lesions are benign, precancerous, or malignant.

Primary Diagnostic Tests

1. Dermatoscopy (Lighted Magnification Exam)

   • Uses a dermatoscope to evaluate lesion structure and pigmentation.

   • Helps determine whether a biopsy is necessary.

2. Skin Biopsy (Gold Standard)

   • Punch biopsy: Provides full-thickness skin sample.

   • Shave biopsy: Removes a superficial layer of skin for analysis.

   • Excisional biopsy: Removes the entire lesion (if necessary).

   • Incisional biopsy: Takes a portion of a larger lesion.

3. Wood’s Lamp Examination (UV Light)

   • Helps differentiate benign vs. malignant pigmentation.

   • Detects fungal infections, vitiligo, or bacterial infections.

4. Tzanck Test (If Herpes Zoster or Viral Infection Suspected)

   • Examines fluid from vesicles to check for herpes virus.

5. Skin Culture (If Infection Suspected)

   • Bacterial, viral, or fungal cultures may be done if the lesion appears infected.

3. Possible Diagnosis Based on Lesions

4. Nursing Priorities for D.A.

1. Educate on Sun Protection

   • Increase SPF to 30+, reapply every 2 hours.

   • Use hats, sunglasses, and protective clothing.

   • Avoid peak sun exposure (10 AM – 4 PM).

2. Encourage Monthly Skin Self-Exams

   • Use the ABCDE rule to check lesions:

     • Asymmetry

     • Border irregularity

     • Color variation

     • Diameter >6mm

     • Evolving changes

3. Support Psychological Well-being

   • Address anxiety about skin cancer.

   • Provide resources on dermatology consultations.

Next Steps

• Schedule a biopsy for histopathological evaluation.

• Monitor lesion changes over time with clinical photography.

• Follow-up with dermatology for further treatment options.

Case Study: Diagnostic Studies Discussion

1. Are These the Expected Diagnostic Tests?

Yes, the dermatoscopy and Wood’s lamp examination are appropriate initial diagnostic tests for evaluating D.A.’s lesions.

• Dermoscopy: Helps assess pigmentation, structure, and vascularity of a lesion to determine if a biopsy is needed.

• Wood’s Lamp Examination: Helps rule out fungal infections or pigmentary disorders.

Since the HCP suspects basal cell carcinoma (BCC), further diagnostic confirmation is necessary.

2. Additional Diagnostic Studies That May Be Ordered

Since BCC is suspected, the following tests may be ordered:

1. Skin Biopsy (Definitive Diagnosis)

   • Punch biopsy: Removes full-thickness skin layers for histopathologic evaluation.

   • Shave biopsy: Removes superficial lesions for analysis.

   • Excisional biopsy: Removes the entire lesion if small enough.

2. Pathology Examination

   • Identifies abnormal cellular changes characteristic of BCC (e.g., basaloid cells, palisading nuclei).

3. Imaging (If Invasive BCC is Suspected)

   • MRI or CT scan: Ordered only if BCC is large, recurrent, or suspected to have deep invasion.

3. Interprofessional Team Priorities for D.A.

1. Confirm Diagnosis

   • Perform a biopsy to determine lesion type and depth.

2. Treatment Planning

   • Surgical excision (Mohs micrographic surgery or standard excision).

   • Topical treatments (e.g., 5-fluorouracil, imiquimod) for superficial BCC.

   • Cryotherapy or electrodessication for small, non-invasive lesions.

   • Radiation therapy (if surgery is contraindicated).

3. Patient Education

   • Sun protection strategies (SPF 30+, protective clothing, avoiding peak sun hours).

   • Importance of skin self-exams to detect new or changing lesions.

   • Psychosocial support to address anxiety about a potential cancer diagnosis.

Bridge to NCLEX Questions & Answers with Rationales

1. The primary function of the skin is

   • Answer: (b) Protection

   • Rationale: The skin acts as a barrier against environmental hazards, pathogens, and fluid loss.

2. Age-related assessment findings of the hair and nails include

   • Answer: (b) Scaly scalp, (d) Thicker, brittle nails, (e) Longitudinal nail ridging

   • Rationale:

     • Aging decreases sebaceous gland activity, leading to dry, scaly scalp.

     • Nail growth slows, causing thicker, brittle nails.

     • Longitudinal ridging occurs due to keratin changes.

3. When assessing the nutritional-metabolic pattern in relation to the skin, the nurse asks about

   • Answer: (c) Recent changes in wound healing

   • Rationale: Poor nutrition affects skin integrity, wound healing, and immune function.

4. Firm, edematous, irregularly shaped skin lesions are called

   • Answer: (a) Wheals

   • Rationale: Wheals are transient, edematous, irregularly shaped lesions seen in hives or allergic reactions.

5. During the physical assessment of a patient’s skin, the nurse should

   • Answer: (c) Pinch up a fold of skin to assess for turgor

   • Rationale: Turgor assessment determines hydration status (tenting may indicate dehydration).

6. Patients with dark skin are more likely to develop

   • Answer: (a) Keloids

   • Rationale: Keloids are hypertrophic scars that extend beyond the wound and are more common in dark-skinned individuals.

7. A blue-gray birthmark on the forehead and eye area in a dark-skinned patient is called

   • Answer: (c) Nevus of Ota

   • Rationale: Nevus of Ota is a bluish-gray pigmentation in the face and eye area, common in Asian and African descent.

8. Diagnostic testing is recommended for skin lesions when

   • Answer: (b) A more definitive diagnosis is needed

   • Rationale: Skin biopsies confirm malignant, infectious, or inflammatory skin conditions.

Final Nursing Considerations

• Monitor biopsy site for infection or delayed healing.

• Educate D.A. on follow-up dermatology appointments.

• Emphasize early detection through regular skin checks.