integumentary system Flashcards
what is the integumentary system
body’s outer layer made of skin, nails, hair, glands and nerves on skin
risk factors for the integumentary system
- nutrition status
- immobility
- pressure ulcers - very high risk
- shearing forces
- UV exposure - natural and artificial (bad sunburns can cause blisters)
- incontinence - when someone urinates and cannot move and is sitting in the moist environment which leads to skin deterioration
health promotion for the skin
- educate client on features of a benign mole
- emphasize steps in skin self-examination
- educate clients about decreasing UV exposure - “seek (shade), slip (a shirt on), slap (on hat and glasses), slop (sunscreen)
signs of skin cancer
asymmetry - shape on one side is different than other
border - irregular, ragged and imprecise - not circular/round shaped
colour - colour variation with brown, black, red, grey or white within the lesion
- normal: one colour
- change in colour (brown to white)
diameter - growth is typical of melanoma
- melanoma usually more than 6 mm in diameter
evolution - look for change in colour, size, shape or symptoms
- changes in growth (leaking,, bigger, itchy)
inspection during integumentary assessment
- if performing complete skin assessment - inspect all body areas
- note the skins appearance - is the colour consistent with the rest of the patients skin tone
- notice any abnormalities (cyanosis, pallor, jaundice, erythema(redness), swelling)
- observe for growth and tumors
- inspect any existing wounds or incisions
- inspect individual lesions
- not if they are elevated, solid or fluid-filled
- not pattern, morphology, size, distribution, body location
- observe for growth and tumors
- inspect any existing ulcers - there are stages
- burns - lead to dehydration
- inspect hair and nails
what are primary lesions
changes in skin that are not associate with other conditions
types of primary lesions
macule
papule
wheal
vesicle
pustule
cyst
macule
flat (non-palpable) spot, discoloured (hyper pigmented or erythematous)
ex: freckle
papule
raised, solid, palpable, less than 1 m in diameter, border well defines
ex: mosquito bite
wheal
raised, red or pale skin patch that itches or burns. vary in shape or size
ex: hives
vesicle
small thin-walled, fluid-filled sacs
ex: herpes, simplex blister
pustule
raised, pus-filled, clear edges
ex: acne, pimple
cyst
encapsulated sac filled with fluid, gas or solid matter. located in upper layer of skin
ex: epidermal cyst
what are secondary lesions
created from primary lesions
types of secondary lesions
scar
excoriation
ulcer
scar
result of primary lesion
- fibrous replacement of local skin structure
excoriation
skin breakdown caused by repetitive scratching/rubbing
ex: scratching a cat scratch until surrounding skin starts to break down
ulcer
loss of skin surface, extending into dermis, subcutaneous, fascia, muscle, bone or all
ex: pressure ulcers
erythema blanchable
indicates early stage of skin irritation or hyperemia (inc. blood flow)
- skin is still healthy, has good circulation and can recover with proper care
erythema non-blanchable
suggests that skin has sustained damage to the deeper layers, often associate with pressure ulcers (bedsores) or tissue injury
- often first sign of pressure ulcer
lifespan considerations in integumentary system: pregnant women
melasma - pigmentation change in face - usually darker - du to hormone changes
linea nigra - line going down center of stomach
lifespan considerations in integumentary system: newborns and infants
vernix - white studd including dead skin cells, WBC, water, etc
Mongolian spot - found in lower back due to cluster of skin pigmentation
lifespan considerations in integumentary system: children and adolescents
acne
lifespan considerations in integumentary system: older adults
sun damaged skin
sagging skin (decreased elastin and collagen)
