Ch 8 Integumentary Examination Flashcards
What does integument examination include?
Observation and inspection of skin, hair, and nails
Skin - Epidermis
Five sublayers of melanocytes, Langerhans’s cells and Merkel’s cells
Avascular
Physical and chemical barrier
Regulate fluid and temperature
Touch sensitization
Excretion
Vitamin D production
Cosmetic appearance
Skin - Dermis
Two sublayers: Papillary and reticular
Contains collagen, elastin, macrophages, mast cells, Meissner’s corpuscles, free nerve endings, and superficial lymph vessels
Highly vascular
Nourishes epidermis
Regulates temperature
Controls infection
Sensitization
Skin - Subcutaneous tissue
Contains adipose tissue, fascia, and some lymphatic vessels
Highly vascular
Sensory structures for cold and pressure
Cushion underlying structures
Allows sliding of skin under shear forces
Screening Inspection Include
Color (Hemosiderin staining, Cyanosis, Jaundice, Erythema)
Temperature
Texture
Moisture
Turgor
Edema and effusion
Malignancy Screening
Distinguish between a common mole and a malignant lesion
Asymmetry
Borders
Color
Diameter
Evolution
Hair
Presence of skin lesions
Changes in hair texture, quantity, or quality
Nails
Pliability, shape, texture, and color
Inflammation vs Infection
Recognize the difference
Color
Temperature
Pain
Swelling
Local function
Drainage
Wound healing
Once a wound exists, the goal is to prevent infection
Pressure Ulcers
Localized areas of soft tissue necrosis from prolonged pressure over bone
Patients at greatest risk
Hospitalization
Long-term care facilities
Spinal cord injury
Higher risk for morbidity and mortality
Many are preventable and treatable
Pressure Ulcers: Risk Factors
Decreased mobility
Can be as little as 2 hours
Shear forces
Impaired sensation
Moisture
Malnutrition
Advanced age
History of previous pressure ulcer
Pressure Ulcers: Common Locations
Based on position
Vast majority are in the lower quarter
Sacrum/coccyx
Greater trochanter
Ischial tuberosity
Posterior calcaneus
Lateral malleolus
Reactive hyperemia
After pressure that turns the skin pale is removed, normal color returns to skin
Erythema
Redness over areas of tissue irritation
Nonblanchable erythema
Areas of redness that do not become pale when pressure is applied
Pressure Ulcers: Stage 1
Skin intact
Localized nonblanchable erythema
At-risk tissues
Pressure Ulcers: Stage 2
Shallow crater
Red/pink wound bed
Loss of epidermis and partial thickness of dermis
Pressure Ulcers: Stage 3
Deep crater
Undermining or tunneling may be present
Loss of epidermis, dermis, and subcutaneous tissue
Pressure Ulcers: Stage 4
Deep crater with extensive necrotic tissue
Undermining or tunneling present
Full thickness loss of tissue with visible bone, tendon, or joint
Pressure Ulcers: Unstageable
Crater with base covered by slough
Unable to determine depth of the crater or level of tissue loss
Pressure ulcer: Suspected deep tissue injury
Deep purple or maroon area of skin discoloration covered by intact skin
Unable to determine actual tissues involved
Vascular Ulcers
Impaired arterial and/or venous blood flow
Leads to wound development
Usually in distal lower extremities
Arterial insufficiency: 5-10%
Venous insufficiency: 70-90%
Arterial Insufficiency
Transport blood from the heart to the periphery
Damage or disease restricts the rate or amount of blood flow
Atherosclerosis
Blood clot
Trauma
Weakening of the smooth muscle within arterial walls
Peripheral artery disease (PAD)
Progressive breakdown of tissues
Venous Insufficiency
Transport blood from the periphery back to the heart and lungs
Ineffective return of blood flow to body core
Damaged vein wall
Dysfunctional valves that prevent back flow
Damaged surrounding musculature
Blood pools in the lower extremities
Increases pressure within veins
Fluid leaks into surrounding interstitial fluid, causing edema
Characteristics of Arterial andVenous Vascular Ulcers
Recognize the differences:
Typical location
Wound appearance
Surrounding tissue appearance
Pain
Distal pulses
Temperature
Common risk factors
Assessment procedures
Identification ofVascular Insufficiency
Peripheral pulse assessment
Venous filling time
Capillary refill time
Ankle-brachial index and toe-brachial index
Pitting edema
Neuropathic Ulcers
Significant sensory loss
Wounds caused by mechanical stress
Most commonly caused by diabetes mellitus
Diabetic neuropathy
Diabetic Neuropathy -Sensory
Damage to small afferent nerve fibers
Most significant risk factor for neuropathic ulcers
Diabetic Neuropathy - Motor
Damage to large efferent motor nerve fibers
Atrophy and weakness of intrinsic foot muscles
Diabetic Neuropathy - Autonomic
Damage to large efferent autonomic nerve fibers
Decreased sweating and oil production in skin
Neuropathic Ulcer Classification - Depth
0: At-risk foot
1: Superficial, noninfected ulceration
2: Deep ulceration, joint or tendon exposed
3: Extensive ulceration, bone exposed
Neuropathic Ulcer Classification - Ischemic
A: Nonischemic
B: Ischemia
C: Gangrene on part of foot
D: Gangrene on entire foot
Other wounds and burns
Skin tears
Surgical wounds
Burns
Depth
Superficial
Superficial partial thickness
Deep partial thickness
Full thickness
Subdermal
Thermal, chemical, or electrical
Blanching
Becoming white; paling to the greatest extent
Cellulitis
Bacterial infection of the connective tissue of the skin
Erythema
Redness of the skin caused by increased local vasodilation
Exudate
Fluid accumulation in a wound bed; mixture of high levels of protein and cells
Fibrin
A whitish, nonglobular protein required for blood clotting
Granulation tissue
A gel-like matrix of vascularized connective tissue with “beefy red” epithelial buds in a newly healing wound bed
Hemosiderin staining
The dark purple-brown color of skin caused by a buildup of iron-containing pigment derived from hemoglobin via disintegration of red blood cells
Induration
Firm edema with a palpable/definable edge
Infection
Invasion and multiplication of microorganisms capable of tissue destruction and invasion, accompanied by local or systemic symptoms
Inflammation
Defensive reaction to tissue injury involving increased local blood flow and capillary permeability that facilitates normal wound healing
Lipodermatosclerosis
A condition characterized by progressive changes to the skin and subcutaneous tissues of the ankle and lower leg in persons with venous insufficiency; characterized by a fibrotic thickening of the skin with hemosiderin staining
Maceration
Softening of intact skin due to prolonged exposure to fluids
Necrotic
Dead; in a wound, devitalized tissue that often is adhered to a wound bed
Pallor
Lack of color; pale
Purulent drainage
Thick yellow, green, or brown wound drainage that often has a foul odor, typically a sign of infection
Serosanguinous
Combination of serous drainage and blood (serous fluid becomes pink)
Serous drainage
Thin fluid that is clear or yellow
Sinus tract
Course pathway that can extend in any direction from a wound surface; results in dead space with potential for abscess fromation
Slough
Loose, stringy necrotic tissue (yellow, white, or tan)
Trophic
Skin changes that occur due to inadequate circulation, including hair loss, thinning of skin, and ridging of nails
Tunneling
Tissue destruction along wound margins in a narrow area that may extend parallel to the skin surface or deeper into the body
Undermining
Area of tissue under wound edges that becomes eroded; results in a large wound beneath a smaller wound opening
Cyanosis
A bluish tint, often seen in the fingers and toes
Serious cause from advanced lung disease, heart disease, and hemoglobin abnormalities (blue lips)
Jaundice
A diffuse yellowing of the skin, also apparent in the whites of the eyes and sometimes in the mucous membranes
Sign of chronic liver disease also hemolytic diseases (destruction of red blood)
