tissue unit 3

Tissue Assessment Overview

This Powerpoint will cover tissue assessment with a focus on assessing the patient's skin.

Aging and the Integumentary System

• Aging affects the integumentary system resulting in:

  • Inactive hair follicles

  • Thinning gray hair

  • Slower epidermal cell division

  • Deterioration of collagen and elastin fibers leading to wrinkles

  • Decrease in subcutaneous fat, sebaceous, and sweat gland function

  • Decreased healing capabilities

Skin Assessment Procedure

1. Information Gathering

   • Subjective Information: Health history, family history of skin disorders, risk factors, and current issues (e.g., diabetes, infections).

   • Objective Informational Gathering: Physical inspection and palpation for color, texture, moisture, temperature, mobility, and turgor.

2. Anatomy of the Skin

   • Largest organ consisting of three layers:

     • Epidermis: Outermost layer with keratin and melanocytes.

     • Dermis: Middle layer with collagen, blood vessels, nerves, and hair follicles.

     • Subcutaneous Layer: Contains adipose tissue that aids in temperature regulation.

3. Skin and Nail Functions

   • Protection, temperature regulation, sensory perception, excretion of waste, and vitamin D production.

Physical Assessment Includes:

• Inspecting skin color and any pigmentation variations:

  • Hyperpigmentation: Increased melanin in certain areas (e.g., sun damage, pregnancy).

  • Hypopigmentation: Decreased melanin (e.g., scars, stretch marks).

  • Unexpected Findings: Cyanosis, ecchymosis, petechiae, erythema, jaundice, and pallor.

Skin Integrity and Lesion Assessment

• Assessing Skin Integrity: Checking for lesions, their characteristics, size, location, and potential drainage.

• Types of lesions: Primary lesions, secondary lesions, vascular lesions, and malignant lesions.

• Use the ABCDE Rule for Melanoma:

  • Asymmetry

  • Border irregularity

  • Color variation

  • Diameter over 6mm

  • Evolving over time.

Skin Temperature, Mobility, and Turgor

• Normal temperatures should match body temperature. Unexpected findings include:

  • Hyperthermia: Indicating fever or localized infection.

  • Hypothermia: Indicating circulatory issues.

• Skin Turgor: Evaluating elasticity; delayed return indicates dehydration.

Edema Assessment

• Types: Generalized or localized edema, with pitting measured by indentation in the skin

  • Pitting scale: +1 (2 mm) to +4 (8 mm).

Nail Assessment

• Inspecting nails for:

  • Shape, thickness, color, capillary refill time (expected < 2 seconds)

  • Unexpected Findings: Color variations indicating potential issues (e.g., clubbed nails, pallor).

Hair Assessment

• Assessing hair distribution, color, quantity, thickness, and texture.

Diagnostic Tests

• Cultures for bacteria, fungi, and viruses.

• Wood's lamp for ringworm and skin testing for allergies (patch or scratch testing).

Conclusion

Used to gather comprehensive subjective and objective data, the tissue assessment is essential for evaluating patient's skin, nails, and overall health.