assessment and diagnostic tests- integumentary
TRANSCRIPT
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Assessment and diagnostic
Tests
Integumentary System
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Largest body organ
Composed of skin, hair , nails and glands
Divided into 2 layers epidermis (outer most)
and dermis (2ndlayer), the subcutaneous tissueis immediately under the dermis
Review of anatomy and Physiology
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Epidermis thin avasular superficial layer made up of
outer dead cornified portion that serves as aprotective 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%) andkeratinocytes (90%)
Review of anatomy and Physiology
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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
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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
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If new cells slough off too rapidly, the skin will appearthin 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 skinproblems - Psoriasis
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2ndlayer collagen bundles and supports the nerve
and vascular network (therefore assists in bodytemperature and blood pressure regulation)
Thickness varies from 1- 4 mm
Has fibroblasts which produce collagen and elastin
fibers and are important in wound healing
Review of anatomy and Physiology
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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
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Hair; Nails ; Glands sebaceous and Sweat glands
(apocrine sweat glands , eccrine sweat glands,ceruminous)
Develop from the epidermal layer and receivenutrients, electrolytes, and fluids from the dermis
Hair and nails form from specialized keratin thatbecomes hardened
Skin Appendages
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Protection : Primary function of the skin
Serves as a surface barrier to external environment andagainst invasion by bacteria, viruses and excessive waterloss
Fat layer insulates the body and provides protection
from trauma Provides sensory perception for environmental
stimuli
Functions of the integumentarysystem
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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
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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 andresults in the loss of the insulating properties of fat
Gerontologic considerations
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Dermal layers thin and skin becomes fragile andtransparent
Capillary loops decrease in number- contribute todelayed wound healing
Sweat and sebeaceous glands decrease( hormonalchanges) in number and functional capacity leadingto dry and scaly skin
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Hair growth diminishes
Thinning of hair in the scalp axilla and pubic areas
Photoaging profound wrinkling, increased loss ofelasticity, mottle, pigmented areas, cutaneousatrophy and benign or malignant lesions
Increased chances of developing bedsores ondependent areas
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Begins at the initial contact with the patient andcontinues throughout the examination
Specific areas of the skin are examined - unless thechief complaint is that of a dermatologic nature
A general statement of the physical condition of theskin 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
Assessment
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Important health Information
Past health history
Will indicate previous trauma, surgery or prior disease thatinvolves the skin
Any changes in the skin color
Specific information related to food , pet, and drugallergies 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 OTCmedications
Subjective Data
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Surgery or other treatments
Biopsy , skin treatments, radiation therapy
Functional health patterns Includes various questions asked by the nurse
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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 orlesions heal?
Health history questions
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Elimination Pattern
Have you noticed changes in your skin related toexcessive sweating, dryness or swelling /
Activity exercise pattern
Do your leisure activities involve the use of anychemicals 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 youafter you have fallen asleep?
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Cognitive
perceptual pattern Do you have any unusual sensations of heat cold or
touch?
Do you have any pain associated with your skincondition?
Do you have any joint pain?
Self perception self concept Pattern
How does your skin condition make you feel aboutyourself?
Role
relationship Pattern Has your skin condition changed your relationships with
others?
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Have you changed your lifestyle because of your skincondition?
Are there any environmental skin irritants at yourcurrent 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 skinproblem?
Coping
Stress Tolerance Pattern
Are you aware of any situation or stressor that changesyour skin condition?
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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?
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Physical examination
Primary skin lesions develop on previously unalteredskin
Some of the common characteristics of primary andsecondary skin lesions are (given in the hand out )
Objective data
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Private examination room of moderate temperaturewith good lighting daylight preferred
Ensure patient is comfortable and in a gown thatallows easy access to all skin areas
Be systematic and proceed from head to toe
Compare symmetric parts
Perform general inspection and then a lesion specificexamination
Use the metric system while taking measurements Use appropriate terminology and nomenclature when
reporting or documenting
General principles
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General color and pigmentation, vascularity orbruising 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 reducedhaemoglobin ( 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 )
Inspection
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The skin is examined for possible problems related tovascularity, such as areas of bruising and vascular andpurpuric lesions such as angiomas
If lesions are found then the
Color
Size
Distribution
Location
Shape - should be recorded
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Skin lesions are usually described in terms related tothe lesions configuration ( pattern in relation to otherlesions) and distribution ( arrangement of lesionsover an area of the skin) Handouts
Important to note any unusual odors colonizedlesions and overgrowth of yeast in overlapping areasare often associated with distinctive odors
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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 isincreased
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
Palpation
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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 surfaceevenly thin in most areas
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Genetic factors determine the skin color of theindividual vary from white to dark brown, yellow,olive red etc.
Darker skin tone result from the reflection of the lightas it strikes the underlying skin pigment
Increased amount of melanin pigment produced bythe melanocytes result in darker skin
Increased melanin natural sun shield thus decreasedincidence of skin cancer in these individuals
Assessment of dark skin
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More difficult to assess than lighter skin
Assessment is more easily made in areas where theepidermis is thin and pigmentation is lighter, such as
Lips
Mucous membrane
Palms
Nail beds
Predisposed to certain skin conditions
Pseudofolliculitis
Keloids
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Before diagnostic testing / procedure , perform an
assessment and document the findings Nursing interventions for diagnostic procedures
includes explaining the procedure to the client andsignificant others and allowing them to ask questions
and express concerns
Diagnostic tests
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Explain appropriate wound care and indications of
possible side effects and complications that should bereported
Provide instructions for follow up appointment
Documentation of diagnostic procedures and the
specific location of the lesion must be completed
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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 culture and sensitivity
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Removal of skin tissue for histologic (cellular
microscopic) assessment or immunofluorescence Punch , excisional , incisional
Local anesthesia is generally used, small gauge 26-30gauge needle is recommended
Procedure is usually quick and almost painless
Skin biopsy
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Skin nodules
Plaques Blisters
And other lesions to rule out malignancy and establishan exact diagnosis
When is skin biopsy performed
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Instruct the client
Avoid using asprin and products containing asprin for 48 hrsbefore 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 antibioticsneed to be given
Obtain informed consent
Client can eat a light meal before the procedure to avoidsyncope
Pre-procedure
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Cover biopsy sites with an antibiotic ointment and aclean bandage or dry dressing unless orderedotherwise
Non-adhesive type of dressings in clients with afragile or sensitive skin and clients with Latex allergy
Remind client that a follow-up assessment isnecessary and appointment should be taken for
suture removal Inform the number of days required for getting the
results
Post Procedure
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Designed to identify the site of an immune reaction
Combines an antigen antibody with a fluorochromedye
Antibodies can be made fluorescent by attachingthem to a dye
Direct immunofluorescence technique to detectauto antibodies directed against portions of the skin
Immunofluorescence
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Indirect immunofluorescence detects specific
antibodies in the patients serum
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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
Potassium Hydroxide Examinationand Fungal culture
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Fine scales from edge of the site are scrapped with a
number 15 scalpel blade or the edge of a glass slideonto a 2ndglass slide
A drop of 10% - 20% potassium hydroxide is added tothe 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
Procedure
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The scrapings are then observed under microscope
Culture scrapings are implanted in the appropriateculture medium
For a nail culture an altered dystrophic nail is snippedand implanted in the medium
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Attempt to identify substances that produce allergic
skin responses Painless procedure
Done to differentiate between an irritant contactdermatitis and an allergic contact dermatitis
Patch testing
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Small amounts of various substances or allergens are
applied to the skin using commercially prepared tapescontaining allergens
The client and significant others need to understandthat low concentration are used
Should not be performed if acute dermatitis ispresent or if the client is taking substantial amountsof oral steroids
Procedure
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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 andconfirms an allergic contact sensitivity
Counseling regarding allergen avoidance or the meaning ofnegative result is a critical part of the test
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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 sentfor cytological examination
Presence of a multinucleated giant cell establishes adiagnosis of viral infection such as herpes simplex orherpes zoster infection
TzancksSmear
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Is a special lamp ( high pressure mercury lamp) that
produces long wave UV rays which results in acharacteristic dark purple fluorescence
The color of the fluorescence is best seen in adarkened room
Differentiates epidermal from dermal lesions andhypo pigmented lesions from normal skin
Wood Lights Examination
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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
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