Ingetumentary Assessment Flashcards
Functions of the Skin (9)
- Protection
- Prevention of Penetration
- Perception
- Temperature Regulation
- Identification
- Communication
- Wound Repair
- Absorption and Excretion
- Production of Vitamin D
Older Adult Considerations: Skin
the skin reflects the changes that all organs experience as a result of aging → slow atrophy of skin structures
- Elastin, collagen, and subcutaneous
fat, and muscle tone are lost
-The loss of collagen increases
the risk of shearing and tearing
injuries
- Healing is prolonged - The outer layer of the epidermis
thins and flattens → wrinkling
occurs because the underlying
dermis also flattens - Sweat and sebaceous glands
decrease in number, leaving the
skin dry
- Decreased response of the
sweat glands to temperature
increase leaves older adults at
an increased risk for heat stroke
(cannot regulate temperature,
cool down)
Older Adult Considerations: Hair
hair loss on the scalp is genetically determined
- The number of functioning melanoxytes decreases, so hair turns grey or white → thin and finea. Males have some symmetrical W-
shapped balding in the frontal
areas
b. Women may have some bristly
facial hairs as estrogen levels
decrease (testosterone is more
prominent)
Older Adult Considerations: Nails
growth rate decreases
- The surface of nails are lustreless
and characterized by longitudinal
ridges that result from local
trauma at the nail matrix
Health History Points
- Previous History of Skin Disease
- Changes in Pigmentation
- Changes in moles
- Excessive Dryness or Moisture
- Pruitis
- Excessive Bruising
- Rash or Lesions
- Medications
- Hair Loss or Growth
- Change in Nails
- Environmental or Occupational
Hazards - Self-Care Behaviours
Seborrhea
Oily skin
Xerosis
Dry skin
Physical Exam Points: Skin (5)
- Colour and Temperature of the Skin
- Moisture, Texture, Thickness
- Edema
- Mobility/ Turgor
- Lesions
Skin: Colour and Temperature (Physical Exam)
a. Pigmentation → normally consistent with ethnicity (note freckles, moles → new vs old)
b. Colour change - (new, acute, longterm) pallor, erythma, cyanosis, jaundice
c. temperature - skin should be warm bilaterally → use back of hand to assess
Pallor
when the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the colour of connective tissue (white)
→ occurs with acute high
stress states such as anxiet or
fear because of the intense
peripheral vasoconstriction
Erythema
an intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries
→ expected with fever, local
inflammation, or emotional
reaction (blushing), often
accompanied by heat
Cyanosis
a blue discolouration that occurs with decreased perfusion or inadequately oxygenated blood
→ occurs with shock
Jaundice
a yellow discolouration indicating rising amounts of bilirubin in the blood
→ first observed in the
junction of the hard and soft
palate in the mouth, and the
sclera
Pigmentation Screening: ABCDE
A. Asymmetry
B. Borders (uneven)
C. Colour (two or more shades
abnormal)
D. Diameter (>0.6cm is
suspicious)
E. Evolution (change) rapidly in
size, shape, pigmentation,
symptoms or morphology
If 2+ criteria are considered abnormal, malignancy is suspected
Physical Exam: Skin Moisture
perspiration appears normally on the face, hands, azilla, and skinfolds in response to activity, a warm environment or anxiety
Abnormal Findings:
a. Diaphoresis - profuse perspiration
b. Dehydration
Diaphoresis
Profuse perspiration
Dehydration (inspection)
look for dehydration in the mucous membranes of the mouth (should normally look smooth and moist with hydration)
- evident in decreased skin turgor
Physical Exam: Skin Texture
normal skin feels smooth and firm with an even surface
Skin Texture: Hyperthyroidism
skin feels smoother and softer, like velvet
Abnormal Findings:
a. Hyperthyroidism - smooth, soft
b. Hypothyroidism - dry, rough
Skin Texture: Hypothyroidism
skin feels rough, dry, and flaky
Physical Exam: Skin Thickness
the epidermis is uniformly thin over most of the body, although thicken callus areas are normal on the palms and soles
Abnormal Finding:
- Skin becomes very thin and shiny
with arterial insufficiency
Physical Exam: Edema
fluid that accumulates in the intercellular spaces (not normally present)
→ Check for edema by imprinting
thumbs firmly against the ankle
malleolus or the tibia → normally
the skin regains a smoothness
immediately, however, if the
pressure leaves a dent, it is
indicative of edema
→ pitting edema graded from 1+ -
4+
Physical Exam: Mobility + Turgor
Mobility: the skin’s ease of movement
Turgor: the ability of the skin to return to original position
- together, assess elasticity of the
skin
To assess: pinch a fold of skin on the anterior aspect of the chest under the clavicle and release
→ abnormal: skin remains peeked,
skin elasticity is low (turgor is low,
dehydration)
→ normal: returns to original
position in <2 seconds
Physical Exam Points: Hair (4)
- Colour - consistent with age
- Texture - dull, coarse, brittle
- Distribution - appropriate for level
of maturity (development) and
gender - Lesions - separate hair into sections
to view the scalp → assess for
cleanliness, presence of dandruff
and lice
Physical Exam Points: Nails (1)
- Shape + Contour - the nail surface is normally slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded
→ Profile Sign - view the index finger
at its profile and note the angle of
the nail base (should be 160o)
Abnormal Finding:- nail clubbing occurs at 180o+
Documenting Lesions
- Colour - unipigmented,
multipigmented
- if exudate is present, note
colour and odour - Elevation - flat, raised, texture
- Pattern - grouping on surface of
skin - Size in cm - exact, use a flexible
ruler - Location and Distribution -
generalized or localized?
Pressure Ulcers
skin defect that extends into the dermis or deeper structure
- Occurs when excessive pressure is
placed on and distorts capillaries
→ occludes blood flow
- appears over bony prominence(s)
→ heels, coccyx, elbows, hips
Risk Factors: anything affecting ability to recognize/ perform ambulation
a. impaired mobility or sensory
perception
b. impaired LOC
c. poor nutrition - nutrients needed
for wounds to heal, if healing is
prolonged, bed rest might be too
d. shearing injury - the fragile sin of
the aging person, moisture from
incontinence/ sweating
Braden Scale
Objective measurement to for skin risk assessment → likelihood of developing pressure ulcers
