Integumentary System
N210 Fall 2007
Rachel Natividad RN, MSN
Variations across the lifespan: Infancy
ACROCYANOSIS
MONGOLIAN SPOT
JAUNDICE
Variations across the lifespan:

Pregnancy

Adolescence
Striae
Cherry Angioma
Linea Nigra
Acne
Variations across the lifespan: Elderly
Changes R/T Aging
Physiological change
Physical Findings
↓ SQ tissue
Thin flat skin
Loss of collagen and elastic
fibers
wrinkles
↑ Capillary fragility
purpuras
↓ sweat gland activity
Xerosis (dry skin)
Over exposure to sun
Liver spots
Loss of or inefficiency of
melanocytes
Liver spots
Elderly: Seborrheic keratoses
Elderly: Senile Lentigines (Liver spots )
WRINKLES
PURPURA
LIVER SPOTS
LIVER SPOTS
Assessing Skin Turgor
Assessment

Subjective data


Specific Skin Complaint
Objective data
Physical assessment: Inspection and palpation
 Draw picture or take photo if possible

Skin Lesions Types

Primary: (Initial lesions) Appear in response to
external or internal environment of skin.
Vesicle,
Bulla
Primary Lesions
Wheal
Nodule
Papule
Tumor
Vesicle
Bulla
Skin Lesion Types
Secondary Lesions: Are a
result of trauma,
chronicity, or infection
of primary lesion.
Secondary Lesions
Crust
Scale
Fissure
Keloid
Lichenification
Skin Lesion Types

Vascular Lesions: Appear as red pigmented lesion.
Could be indicative of bleeding

Hemangiomas


Telangiectasias


port wine stain; strawberry mark-mature hemangioma
spider angioma with pregnancy or liver disease; venous
lake
Purpuric Lesions



Petechiae
Ecchymoses
purpura
Vascular Lesions- Cont.
HEMANGIOMA
Petechiae
Ecchymosis
Spider Angioma
Venous Lake
TELANGIECTASIA
Vascular Lesions: Purpura
Shapes and Configurations
EXERCISE
Documentation of Skin Lesions
COLOR
SHAPE/CONFIGURATION
TYPE
SIZE
(L x W x D) in cm
DISTRIBUTION/
PATTERN

EXUDATES
 Amount
 Color/consistency
 Serous
 Serosanguinous
 Sanguinous
 Purulent
Pattern Injury from Physical Abuse




Lesions due to trauma or
abuse
Bruise or wound whose
shape suggests the
instrument or weapon that
caused it
Physical signs with history
that does not match the
severity or type of injury
indicates abuse
Scalding injury, belt marks,
bite marks, cigarette burns,
deformity from untreated
fracture
Pattern Injuries
Pattern Injury: Distribution
Diagnostic Tests


Culture
Skin Biopsies
Punch
 Shave
 Excisional




Woods Light
Diascopy
Skin Testing
Parasitic Infestations
Pediculosis
Scabies
Cause
lice
Symptom &
Areas affected
Head, body, pubic Finger webs,
area
creases of abd,
wrist, axilla,
breasts
Pyrethroid (Rid) Lindane,
pyrethroid
Treatment
Itch mite
Parasitic Infestations
CAPITIS
CORPORIS
PUBIS
Infestations cont.

Scabies

A contagious disease

Transmission: close and
prolonged contact or
infected bedding
Infestations Cont.

Scabies lesion
distribution
Pressure Ulcers

Tissue damage caused by the skin and
underlying soft tissue are compressed between
bony prominence and an external surface for an
extended period.
Pressure Ulcers
Pressure Ulcers
CAUSES (6)
RISKS (4)
PREVENTION (5)
Pressure Ulcers
CAUSES (6)
RISKS (4)
PREVENTION (5)
Pressure
Mental Status
Sensory Perception
Pressure Relief
Shearing
Activity
Mobility
Prevention of
contractures
Friction
Friction Relief
Moisture
Incontinence
Skin care
Nutrition
Nutritional
Deficiencies
Nutritional Suuport
Circulation
Staging of Pressure Ulcers
Pressure ulcers and their features are classified and
assessed in stages:
Stage
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
Description
Stage 1 Pressure Ulcer
Stage 2 Pressure Ulcer
Stage 3 Pressure Ulcer
Stage 4 Pressure Ulcer
Stage 4 with Necrosis
Eschar- unstageable
Ulcer Assessment

Describe ulcer





Appearance




Stage
Location
Size
Shape
Drainage
Odor
Stage
Presence of infection



Foul smell
Purulent drainage
Heat, extreme redness, edema