Assessment of the Integument

  • Skin Layers and Functions

    • Epidermis, Dermis, Hypodermis (Subcutaneous)

    • Largest organ of the body, averaging about 20 square feet for adults; crucial for protection, sensation, and regulatory functions.

  • Age Related Changes

    • Intrinsic Age Factors: Fine wrinkles, thinness, dryness, graying hair, and thinning nail plates from decreased cell turnover and elasticity.

    • Extrinsic Age Factors: Environmental influences like smoking, prolonged sun exposure, obesity, and pollution significantly accelerate skin aging.

  • Subjective Data Gathering

    • Thorough history to evaluate previous skin diseases, changes in pigmentation, symptoms of xerosis (dry skin), pruritus (itching), excessive bruising, rashes, or lesions.

  • Objective Data Gathering

    • Comprehensive physical examination focusing on skin temperature, color, moisture levels, turgor, and overall skin integrity, including assessments for skin lesions and abnormalities.

  • Assessment of Skin Colors

    • Recognizing abnormalities, including blanching vs non-blanching and color changes such as:

    • Pallor: Loss of red tones

    • Erythema: Intense redness

    • Cyanosis: Bluish tinge

    • Jaundice: Yellowing

  • Epidermal Appendages

    • Comprise hair, nails, Eccrine and Apocrine sweat glands, and Sebaceous glands, serving important roles in skin health and temperature regulation.

  • Primary Functions of Skin

    • Surface barrier against pathogens

    • Contributes to immunity

    • Synthesizes Vitamin D

    • Enables sensory perception

    • Maintains fluid and electrolyte balance

    • Regulates temperature

    • Plays a role in body image and emotional expression.

  • Newborn Skin Characteristics

    • Newborns have ineffective temperature regulation; eccrine glands do not function optimally initially.

    • Sebum produced aids in moisture retention and skin protection.

  • Skin Inspection: Color Assessment

    • Pallor: Loss of red-pink tones; indicative of anemia or vasoconstriction.

    • Erythema: Intense redness from increased blood flow; observed in infections or emotional responses.

    • Cyanosis: Bluish color from deoxygenated blood; associated with respiratory/cardiovascular issues.

    • Jaundice: Yellow discoloration from bilirubin accumulation; note initial presentation in sclera and later in palate.

  • Abnormal Skin Findings

    • Primary vs Secondary Skin Lesions

    • Primary: Develop on undamaged skin (e.g., macules, papules, vesicles).

    • Secondary: Alterations to primary lesions (e.g., crusts, eschar).

  • Measuring Lesions:

    • Measure length (longest point), width (widest point), and depth; evaluate for tunneling or undermining indicative of deeper tissue involvement.

  • Wound Management: Types of Dressings

    • Hydrocolloids for moderate drainage

    • Alginates for heavy exudate

    • Hydrogels for dry wounds

    • Dry gauze for protective coverage

    • Transparent sheets for inspecting wounds

  • Wound Healing Processes

    • Primary Intention: Clean surgical wounds heal quickly with minimal scarring.

    • Secondary Intention: Wounds like abrasions or deep pressure injuries heal by granulation tissue formation; may lead to increased scarring.

  • Assessing Pressure Injuries: Braden Scale

    • Systematic method to measure risk of pressure injuries (score of 9 or less = very high risk; score of 19-23 = no risk) focusing on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

  • Conclusion

    • Skin assessment is essential for identifying issues related to integrity, sensation, temperature regulation, and potential infections.

    • Proper education, early detection, and monitoring are key to promoting healing and overall skin health.