Chapter 51: Nursing Assessment: Integumentary Function
Anatomy and Physiology of the Skin
Functions of the Skin
 Protection: Prevents trauma and entry by bacteria and other foreign matter
 Sensation
 Fluid and electrolyte balance: The stratum corneum has the capacity to absorb water
 Thermoregulation
 Vitamin D synthesis
 Immunity: Langerhans cells facilitate the uptake of IgE-associated allergens
Assessment of Patients With Skin Disorders #1
 Health history should address skin allergies; allergic reactions to food, medications, and chemicals;
previous skin problems; and skin cancer
 Assessment of the skin involves the entire skin area, including the mucous membranes, scalp, hair, and
nails
 Assessing color:
o Erythema: Redness of the skin from congestion of capillaries (associated with inflammation)
o Cyanosis: Bluish color from lack of oxygen
o Jaundice: Yellowing from high serum bilirubin
Assessment of Patients With Skin Disorders #2
 Striae: Stretch marks
 Rashes should be examined closely under bright light
 Lesions should be examined for:
o Color
o Redness, heat, pain, or swelling
o Size and location of the involved area
o Pattern of eruption
o Distribution
Assessment of Patients With Skin Disorders #3
 Wound assessment should include:
o Examination of the wound bed
o Examination of the wound edges
o Measurement of the wound
o Examination of the surrounding skin
 Vascularity should be assessed (e.g., presence of changes such as angiomas and petechiae)
 Nails and patterns of hair growth/loss should be assessed
Diagnostic Evaluation
 Skin biopsy: Performed to obtain tissue for microscopic examination
 Patch testing: Performed to identify substances to which the patient has developed an allergy
 Skin scrapings: To sample for suspected fungal lesions
 Clinical photographs: To document the nature and extent of the skin condition