Examination of the integumentary system

Physical examination

General   survey

·         Observationof the client's general appearance, walking gait

·         Measurementof vital signs, height, and weight

·         Client’s body build, posture

·         Hygiene, and mental status

·         Mental status and appearance

·         Observe client's posture and gait, standing, sitting, and walking.

·         Client’s overall hygiene and grooming

·         Note body and breath odor

·         Observe for signs of distress in posture

·         Assess the appropriateness of the client's responses.

Vital Signs
To establish baseline data against

To compare future measurements and to detect actual and potential health problems

Height and weight

Examination of the integumentary system

The integument involves the skin, hair and nails.

Assessment of skin involves inspection and palpation.

Olfactory sense to detect unusual skin odour.

Rashes/Pruritus: The examiner should ask how long the area has been present, whether it itches, and whether it appeared abruptly or seemed to start in a specific area and spread. Patient input as to possible causative factors of any rashes should be ascertained.

Bruising/Bleeding: The patient should be questioned as to any history of unusual bruising or bleeding which could indicate a problem with clotting disorders. Bleeding from moles should be also be noted as this could indicate cancer of the skin.

Nevi/Moles: The patient should be asked if there has been any changes in the size or shape of existing nevi or moles.

Dryness/Sweating: Problems with dry skin or excessive sweating may indicate endocrine disorders such as hypothyroidism.

 Excessive sweating at night may be indicative of tuberculosis.

Pungent body odor is frequently due to poor hygiene,

Hyperhydrosis (excessive perspiration)

Bromhydrosis: foul smelling perspiration

Previously Diagnosed Skin Diseases: It is important to assess previously diagnosed skin disorders such as psoriasis or eczema to provide baseline information

Physical assessment of the skin begins with a general inspection followed by a detailed examination. When preparing to assess the skin, wear gloves if the patient has any lesions, complains of itching skin, or if the mucous membranes are to be examined.

Colour: Note the colour of the skin first. Depending upon the person’s race the skin should be flesh-toned appropriate for the person.

Pallor- inadequate circulating blood or Hb. Most readily seen in conjunctiva, buccal mucus membrane, nail beds, palms of the hand and soles of the feet.

Cyanosis: Bluish tinge, most evident in nail beds, lips, Buccal mucosa.

Jaundice: yellowish tinge first evident in sclera and then mucus membranes and skin
posterior part of the hard palate is specific to jaundice

Erythema- redness associates with rashes

Hyperpigmentation: Localised areas of increased pigmentatione.g. Birth mark
Hypopigmentation: Localized areas of decreased pigmentation eg.vitiligo due to destruction of melanocytes,
Albinism complete or partial loss of melanin in hair,skin, eyes

Edema: Presence of excess interstitial fluid- appears swollen, shiny and taut. Generalized edema is usually due to impaired venous circulation.

Moisture- hydration of skin and mucus membrane reveals body fluid imbalances.  Dry skin can be caused by irritating soap, excessive bathing, or hypothyroidism; dry skin is normally found in elderly people.

Texture- refers to character of the surface of skin

Temperature: Use the back of the hand to assess skin temperature for coolness or warmth.

Turgor:refers to elasticity of skin. When pinched between the thumb and index finger for a few seconds, normally hydrated, taut skin will snap back into place when released. Dehydrated skin or the skin of the elderly patient will form a small tent shape before gradually assuming its normal position.

Odor: Note any unusual body odor and breath odor.

Scars: Assess for cause, location, appearance (colour and size), and degree of tenderness.

Masses: Note location, size, depth, and presence of tenderness.

Lesions: Lightly palpate any lesions to detect tenderness, firmness, and depth. Measure length, width, and depth

Birthmarks/Moles: Note location, colour, shape, and size. Assess with the following four warning signs (ABCD) that might indicate the presence of skin cancer:

1. Asymmetrical edges. 2. Skin cancers have irregular borders while non-cancerous growths have smooth, even borders. 3. Refers to colour. Note if the nevus has various coloured areas instead of being one colour. 4. Stands for diameter. Generally, nevi under one-half centimetre in diameter are not cancerous. However, nevi that are larger than this can indicate skin cancer.

Primary lesions

Primary lesions are those originally produced by trauma or other stimulation

Macule: A flat, small (1 centimetre or less) lesion with colour change. Flat moles, measles, petechiae and freckles are the examples of macule. Macule that is more than in (1 cm) in diameter is called a patch; it has an irregular in shape.

Papule: An elevated, sharply circumscribed, small (1 centimetre), colour lesion. May be pink, red, or any variation. Seen in ringworm and psoriasis       
Tumours are larger than 2cm with irregular border

Nodule:  elevated solid hard mass that extend deeper in to the dermis than a papule. Circumscribed, 0.5 to 2 cm.  

Cyst 1 cm or larger, elevated, encapsulated fluid filled or semisolid mass arising out of S/C tissue or dermis

Plaque: A patch of closely grouped papules more than in (1 cm) across. Lesions are rough in texture and colour brown, red, or pink. The size is larger than 1 cm. Rubeola and psoriasis are examples
Vesicle or blister: A bulging, small (under 1 centimetre), sharply defined lesion filled with clear, free fluid. Seen as groups in herpes simplex, varicella, and herpes zoster.
Bullae: Large (over 1 centimetre) vesicles. Seen on soles and palms in scarlet fever and in sunburn

Pustule: An elevated, sharply circumscribed lesion (less than 1 centimetre) filled with pus. Seen in impetigo, acne, and staphylococcus infections.
Wheal:  An elevated, white to pink edematous lesion that is unstable and associated with Pruritus. Usually cause by an allergic reaction, insect bites or reaction from drugs. Hives, urticaria and mosquito bites are examples.

Petechiae: Tiny, reddish purple, sharply circumscribed spots of haemorrhage in the superficial layers of the skin or epidermis. Petechiae may indicate severe systemic disease e.g.Meningococcemia, bacterial endocarditis, or non-thrombocytopenic purpura.

Secondary lesions:result from some alteration, usually traumatic, to the primary lesion.

Atrophy:  translucent, dry skin surface due to wasting or loss of collagen and elastin
Scales: Dried fragments of sloughed dead epidermis. Colour may be whitegrey or silver

Excoriation: Mechanical removal of the epidermis leaving dermis exposed. Scratch or scrape of original lesion. Linear erosion induced by scratching.

Erosion: wearing away of the superficial epidermis causing a moist, shallow depression. E.g. StevenJohnson syndrome.

Ulcer: Destruction and loss of epidermis, dermis, and possibly subcutaneous layers.
Fissure: A vertical, linear crack through the epidermis and dermis.

Scar: Formation of dense connective tissue resulting from destruction of skin.

Lichenification: Pronounced thickening of the epidermis and dermis from chronic scratching or rubbing. e. g. chronic dermatitis.
Keloid: Elevated irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing

Nail

Inspect nail bed for colour, length, symmetry, cleanliness

Assess thickness and shape of nail. Assess Angle between nail and nail bed

To assess capillary refill:blanch test -press down on one of the patient’s nails until it pales. Release the nail and observe for the pink colour to return. The normal colour should return in less than 3 seconds. Capillary refill can be affected by room and body temperature, vasoconstriction from smoking, or peripheral edema.

Finger clubbing: a sign of chronic tissue hypoxia, occurs when the angle between the fingernails and where the nails enters the skin increase. Normal concave nail bases will create a small, diamond-shaped space when the nails of the index fingers of each hand are placed together. Clubbed fingers are convex at the bases and will touch without leaving a space.

Spoon shaped nails (koilonychias) - iron deficiency anemia

Texture – normally smooth

Excessively thick nails- elderly, poor circulation, chronic fungal infection.

Excessively thin nails/ presence of grooves or furrows- may reflect iron deficiency anemia.

Paronychia- inflammation of tissues surrounding the nail.

Beau’slines are horizontal depressions in the nail that can result frominjury or severe illness. 

Splinter haemorrhages- red or brown linear streaks in nail bed    - seen in trauma, endocarditis

Hair

Assessing clients’ hair includes inspecting the hair, considering developmental changes and ethnicity differences and determining individual hair care practices & the factors influencing them

Hair: Determine any recent colour changes (to include the use of dyes or other chemicals), texture, abnormal loss or growth distribution, lesions of scalp, and baldness. Assess hair for growth distribution, texture, and infestation with lice.

Severe protein deficiency (kwashiorkor) - the hair colour is faded appears reddish or bleached, and the texture is coarse and dry.

Alopecia (hair loss) -hypothyroidism can cause very thin and brittle hair.

Hirsutism – hair growth on upper lip, chin, cheeks- due to endocrine disorders

Poor nutrition cause dull, dry, thin hair

Dandruff or psoriasis cause dryness of scalp

Excessive oily hair- in androgen hormone stimulation

Document  in the record.

Inspect the evenness of hair growth	Evenly distributed	Patches of hair loss
Inspect hair thickness/ thinness	Thick hair	Very thin hair( hypothyroidism)
Observe texture & oiliness	Silky, resilient hair	Brittle, excessively oily/ dry
Presence of infection/infestation	No infection	Flaky, sore, lice nits
Inspect amount of body hair	variable	Hirsutism (abnormal hairiness in women)