History And Physical Assessment

Of Integumentary System

By:
Mr. M . Shiva Nanda Reddy
 Introduction:
• Skin disorders are encountered frequently in
nursing practice.
• Skin-related disorders account for up to 10%
of all ambulatory patient visits .
• In certain systemic conditions, such as
hepatitis and some cancers, dermatologic
manifestations may be the first sign of the
disorder.
• So its very essential to know the assessment of
integumentary system.
Subjective Data / History Collection:
• Present health history:
Specific information about the onset, signs and

symptoms, location, and duration of any pain,

itching, rash, or other discomfort experienced by
the patient need to be collected.
Past Health History:-
• Past health history of trauma, surgery, or disease
that involves the skin
• Determine if the patient has noticed any
dermatologic manifestations of systemic
problems such as jaundice (liver disease),
delayed wound healing (diabetes mellitus),
cyanosis (respiratory disorder), or pallor
(anemia).
Medications:
• A thorough medication history is important,
especially in relation to vitamins, hormones,
antibiotics, corticosteroids, and antimetabolites
because these may cause side effects that are
manifested in the skin.

• If a medication is used, record the name, length

of use, method of application, and effectiveness.
Surgery or Other Treatments.
• Determine if any surgical procedures, including
cosmetic surgery, were performed on the skin.

• Note any treatments specific for a skin problem

(e.g., phototherapy) or for a health problem (e.g.,
radiation therapy).

• In addition, document any treatments undergone

primarily for cosmetic purposes.
Health Perception–Health Management
Pattern
• Question the patient about health practices
related to the integumentary system, such as
self-care habits related to daily hygiene.
• Document the frequency of use and sun
protection factor (SPF) of sunscreen products.
• Assess the use of personal care products (e.g.,
shampoos, moisturizing agents, cosmetics).
• Note any medications used for treating hair
loss.
Family history:
• Obtain information about any skin diseases,
including congenital and familial diseases (e.g.,
alopecia, psoriasis) and systemic diseases with
dermatologic manifestations (e.g., diabetes,
thyroid disease, cardiovascular diseases, immune
disorders).
• In addition, note any family and personal history
of skin cancer.
Psoriasis
Nutritional history:
• A diet history reveals the adequacy of
nutrients essential to healthy skin such as
vitamins A, D, E, and C; dietary fat; and
protein.

• Note any food allergies that cause a skin

reaction.
Elimination Pattern.
• Ask the patient about conditions of the skin
such as dehydration, edema, and pruritus
(itching), which can indicate alterations in
fluid balance.

• If urinary or fecal incontinence is a problem,

determine the condition of the skin in the anal
and perineal areas.
Activity-Exercise Pattern
• Obtain information about occupational
hazards in relation to exposure to known
carcinogens, chemical irritants, and allergens.
Sleep-Rest Pattern:
• Question the patient about disturbances in
sleep patterns caused by a skin condition.

• For example, pruritus can be distressing and

cause major alterations in normal sleep
patterns.
Cognitive-Perceptual Pattern:
• Determine the patient’s perception of the
sensations of heat, cold, pain, and touch.

• Assess and record any joint pain.

• Assess the mobility of the joints, since the

patient’s skin condition may cause alterations
in mobility.
Role-Relationship Pattern.
• Determine how the patient’s skin condition
affects relationships with family members,
peers, and work associates.
 Objective Data /
Physical Examination
• Assessment of the skin involves the entire skin area,
including the mucous membranes, scalp, hair, and
nails.
• The skin is a reflection of a person’s overall health,
and alterations commonly correspond to disease in
other organ systems.
• Inspection and palpation are techniques commonly
used in examining the skin.
Principles when assessing the skin are as follows:
• Have a private examination room of moderate temperature with
good lighting.
• Ensure that the patient is comfortable and in a dressing gown that
allows easy access to all skin areas.
• Be systematic and proceed from head to toe.
• Compare symmetric parts.
• Perform a general inspection and then a lesion-specific
examination.
• Use the metric system when taking measurements.
• Use appropriate terminology and nomenclature when reporting or
documenting.
 Inspection.

• The general appearance of the skin is assessed

by observing color, temperature, moisture or
dryness, skin texture (rough or smooth),
lesions, vascularity, mobility, and the
condition of the hair and nails.
 Palpation

• Skin turgor, possible edema, and elasticity are

assessed by palpation.
Gradings of pitting edema
• Skin color varies from person to person and
ranges from light pink to deep brown to
almost pure black.

• The skin of exposed portions of the body,

especially in sunny, warm climates, tends to
be more pigmented than the rest of the body.
• The vasodilation that occurs with fever,
sunburn, and inflammation produces a pink
or reddish colour to the skin.

• Pallor is an absence of or a decrease in normal

skin color and vascularity and is best observed
in the conjunctivae or around the mouth.
• The bluish hue of cyanosis indicates cellular
hypoxia and is easily observed in the
extremities, nail beds, lips, and mucous
membranes.

• Jaundice, a yellowing of the skin, is directly

related to elevations in serum bilirubin and is
often first observed in the sclerae and mucous
membranes
 Erythema
• Erythema is redness of the skin caused by the
congestion of capillaries.
• In light-skinned people, it is easily observed at
any location where it appears.
• it may be difficult to detect erythema in dark
skinned persons as the skin turns to purple
grey due to increases blood supply.
Erythema
Pallor
Jaundice
• Cyanosis
 Cyanosis
• Cyanosis is the bluish discoloration that results from a
lack of oxygen in the blood.

• It appears with respiratory or circulatory compromise.

• Cyanosis manifests as a bluish hue to the lips,

fingertips, and nail beds.

• To detect cyanosis, the areas around the mouth and

lips and over the cheekbones and earlobes should be
observed
 Color Changes

Observe for hypopigmentation (ie, decrease in

the melanin of the skin, resulting in a loss of
pigmentation) and hyperpigmentation (ie,
increase in the melanin of the skin, resulting in
increased pigmentation).
 ASSESSING SKIN LESIONS
• Skin lesions are the most prominent
characteristics of dermatologic conditions.
• They vary in size, shape, and cause and are
classified according to their appearance and
origin.
Described the lesions clearly and in detail:
• Color of the lesion
• Any redness, heat, pain, or swelling
• Size and location of the involved area
• Pattern of eruption (eg, macular, papular,
scaling, oozing)
• Distribution of the lesion (eg, bilateral,
symmetric, linear, Circular)
 Classification of skin lesions:
• Skin lesions may be primary or secondary skin lesions.
• Primary lesions are the initial lesions and are
characteristic of the disease itself.
• Secondary lesions result from external causes, such as
scratching, trauma, infections, or changes caused by
wound healing.
• Depending on the stage of development, skin lesions are
further categorized according to type and appearance
 Primary Skin Lesions
Macule & Patch:
• Flat, nonpalpable skin color change (color may be
brown, white, purple, red)

• Macule: <1 cm, circumscribed border

• Patch: >1 cm, may have irregular border

• Example: flat mole

Macule Patch
Papule & Plaque
 Papule

 Elevated, palpable, solid mass

 Circumscribed border
Plaque
 coalesced papules with flat top

 Papule <0.5 cm

 Plaque >0.5 cm

Examples:

Papules: warts

Plaques: Psoriasis
papule
plaque
Nodule & Tumor
Elevated, palpable, solid mass
Extends deeper into the dermis than a papule
• Nodule: 0.5–2 cm; circumscribed
• Tumor: >1–2 cm; tumors do not always have sharp
borders
Examples:
Nodules: Lipoma
Tumors: Larger lipoma, carcinoma
Nodule
tumour
Vesicle & Bulla:
Circumscribed, elevated, palpable mass containing
serous fluid
• Vesicle: <0.5 cm
• Bulla: >0.5 cm
Examples:
Vesicles: Herpes simplex/zoster, chickenpox,
second-degree burn (blister)
Bulla: Pemphigus, large burn blisters
Vesicle & Bulla:
Wheal:
Transient (temporary) elevated mass which
usually disappers in 24 hours.
Borders often irregular
 Caused by movement of serous fluid into the
dermis
Example: Insect bites
wheal
• Pustule

• Pus-filled vesicle or bulla

• Example: Acne
pustule
Cyst
• Encapsulated fluid-filled or semisolid mass

• In the subcutaneous tissue or dermis

Examples:
Sebaceous cyst
cyst
 SECONDARY SKIN LESIONS
Erosion:
• Loss of superficial epidermis
• Does not extend to dermis
• Depressed, moist area
Examples:
Ruptured vesicles, scratch marks
erosion
Ulcer:
• Skin loss extending past epidermis

• Necrotic tissue loss

• Bleeding and scarring possible

Example: pressure ulcer

ulcer
Fissure

• Linear crack in the skin

• May extend to dermis

Examples:

Cracked foot, lips

fissures
Scales
•scales are secondary to desquamated, dead epithelium.

• Flakes may adhere to skin surface

• Color varies (silvery, white)

• Texture varies (thick, fine)

Examples:

Dandruff, psoriasis
scales
Crust
• Dried residue of serum, blood, or pus on

skin surface

Example:

Residue left after vesicle rupture

crust
Scar (Cicatrix):
• Skin mark left after healing of a wound or lesion

Examples:

Healed wound or surgical incision

scar
Keloid
• Hypertrophied scar tissue

• Secondary to excessive collagen formation

during healing

Example:
Keloid of surgical incision
keloid
Atrophy
• Thin, dry, transparent appearance of epidermis
• Secondary to loss of collagen and elastin
• Underlying vessels may be visible
Examples:
Aged skin
Atrophy:
Lichenification:
• Thickening and roughening of the skin

• May be secondary to repeated rubbing, irritation,

scratching

Example:

Contact dermatitis
Lichenification:
 VASCULAR SKIN LESIONS
Petechia:
• Round red or purple macule

• Small: 1–2 mm

• Secondary to blood extravasation

• Associated with bleeding tendencies

petechiae
Ecchymosis
• Round or irregular macular lesion

• Larger than petechia

• Secondary to blood extravasation

• Associated with trauma, bleeding tendencies

Ecchymosis
Cherry Angioma:
• Papular and round

• Red or purple

• Noted on trunk, extremities

• May blanch with pressure

• Normal age-related skin alteration

Cherry angioma
Spider Angioma
• Red, arteriole lesion

• Central body with radiating branches

• Noted on face, neck, arms, trunk

• Associated with liver disease, pregnancy, vitamin

B deficiency.
Spider angioma
Telangiectasia (Venous Star)
• Shape varies: spider-like or linear

• Color bluish or red

• Does not blanch when pressure is applied

• Noted on legs, anterior chest

• Secondary to superficial dilation of venous vessels and

capillaries

• Associated with increased venous pressure states

Telangiectasia
 Assessing Vascularity and Hydration
• A description of vascular changes includes location,
distribution, color, and size.
• Common vascular changes include petechiae,
ecchymoses, angiomas, and venous stars.
• Skin moisture, temperature, and texture are assessed
primarily by palpation.
• The elasticity (ie, turgor) of the skin decreases
normally with aging.
 Assessing the Nails
Observe the nails for the signs and symptoms of
beaus lines( Transverse depressions), koilnychia
(spoon shaped nails)and clubbing (the angle
between the nail and the base of the nail will be
greater than 180 degrees) and paronychia
(inflammation of the skin around the nails).
 Assessment Of Hair:
• The hair assessment is carried out by inspecting and
palpating.
• Gloves are worn, and the examination room should be
well lighted.
• Separating the hair so that the condition of the skin
underneath can be easily seen.
• The nurse assesses color, texture, distribution and
any abnormal lesions, evidence of itching, inflammation,
scaling, or signs of infestation (ie, lice or mites) are
documented
Natural hair color ranges from white to black.

Hair color begins to gray with age, initially

appearing during the third decade of life,
when the loss of melanin begins to become
apparent.