History And Physical Assessment

Of Integumentary System

Mrs.Nilakshi Barik
Lecturer
 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
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

Macul Patc
e h
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
papul
e
plaqu
e
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
Nod
ule
tumo
ur
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
whe
al
• Pustule

• Pus-filled vesicle or
bulla
• Example: Acne
pust
ule
Cys
t• Encapsulated fluid-filled or semisolid
mass
• In the subcutaneous tissue or dermis

Examples:
Sebaceous cyst
cy
st
 SECONDARY SKIN LESIONS
Erosion:
• Loss of superficial epidermis
• Does not extend to dermis
•Depressed, moist area

Examples:
Ruptured vesicles,
scratch marks
erosio
n
Ulcer:
• Skin loss extending past
epidermis
• Necrotic tissue loss

•Bleeding and scarring possible

Example: pressure ulcer

ulce
r
Fissure
• Linear crack in the
skin

•May extend to dermis

Examples:
Cracked foot, lips
fissu
res
Scale
s•scales are secondary to desquamated, dead epithelium.
• Flakes may adhere to skin surface

• Color varies (silvery, white)

•Texture varies (thick, fine)

Examples:

Dandruff, psoriasis
scale
s
Crus
t
• Dried residue of serum, blood, or pus
on

skin

surface

Example:
Residue left
crus
t
Scar
(Cicatrix):
• Skin mark left after healing of a wound or
lesion

Examples:

Healed wound or surgical incision

sc
ar
Keloi
d
•Hypertrophied scar tissue
•Secondary to excessive collagen formation
during healing

Example:
Keloid of surgical incision
keloi
d
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
petechia
e
Ecchymosi
s
• Round or irregular macular lesion

• Larger than petechia

• Secondary to blood extravasation

• Associated with trauma, bleeding

tendencies
Ecchymosi
s
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

Telangiectasi
a
 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
 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.