1. Medical-Surgical Nursing Care Third Edition CHAPTER Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby The Integumentary System and Assessment 44

2. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Figure 44-1 Anatomy of the skin.

3. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Epidermis Protection Prevents water loss Water repellent Stores melanin Vitamin D Phagocytes

4. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Dermis Regulates body temperature Nerve endings

5. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Glands Oil glands –Sebum is lubrication and kills bacteria Eccrine sweat glands –Regulate body heat Other sweat glands –Perspiration and waxy cerumen

6. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Hair/Nails Hair –Cushions scalp –Protection –Insulation Nails –Protection –Grasping and other activities

7. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skin Color Result of varying levels of pigmentation Melanin –Yellow to brown pigment –Produced in greater amounts in persons with dark skin Exposure to sun causes a buildup in melanin, causing light skin to tan

8. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skin Color Caucasian skin has very little melanin –Color of red blood cells gives skin pinkish tone Influenced by emotions or illnesses Erythema –Reddening of skin –Caused by blushing, fever, inflammation, hypertension

9. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skin Color Cyanosis –Bluish discoloration of skin and mucous membranes –Results from poor oxygenation of hemoglobin, lack of adequate RBCs or hemoglobin Pallor –Paleness of skin –Caused by shock, fear, anemia, anger, or hypoxia

10. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skin Color Jaundice –Yellow to orange color visible in skin and mucous membranes –Usually results from a liver disorder

11. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Integumentary System - Assessment Health History –Changes in health, skin color, dryness, or oiliness –Growth or changes in warts or moles –Presence of lesions –Delayed wound healing –Determine whether client takes hormones, vitamins, or antibiotics that cause skin side effects

12. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Integumentary System - Assessment If client complains about itching, ask client to describe and identify any precipitating causes such as medications, soaps, Inquire about excessive hair loss For nail problems ask about nail splitting, breakage, discoloration, infection, diet, exposure to chemicals

13. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Integumentary System - Assessment Obtain past medical Rx, previous problems with allergies, surgeries, or lesions Skin problems can indicate other health disorders such as cardiovascular, hematologic, diabetes mellitus, thyroid, and liver problems

14. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Integumentary System - Assessment Family Hx of skin cancer, light-colored hair and eyes, excessive exposure to sun, and skin trauma Explore risk factors for malignant melanoma—large moles, family history of melanomas, freckling and sun burning

15. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Integumentary System – Physical Examination Inspect skin –Pallor –Cyanosis –Rashes –Inflammations –Lesions –Bruising

16. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby

17. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby

18. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby TABLE 44-2 (continued) Primary and Secondary Skin Lesions

19. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Integumentary System – Physical Examination Vitiligo –Abnormal patchy loss of melanin over face, hands, and groin Petechiae –Small reddish purple pinpoint spots over abdomen and buttocks Check skin temperature, texture, moisture, and turgor

20. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Integumentary System – Physical Examination Inspect skin for tenting or edema Hair distribution—hirsutism (excessive hair) or alopecia Inspect scalp for lesions, pustules, and nits Inspect nails for clubbing, nail beds for red splinter hemorrhages

21. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skin Changes in Older Adult Loss of subcutaneous tissue Dermal thinning Decreased elasticity causes wrinkles and sagging Turgor decreased

22. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skin Changes in Older Adult Inability to respond to heat and cold quickly –Increased risk for heat stroke and hypothermia

23. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skin Changes in Older Adult Loss of oil and sweat gland causes dry itchy skin Flat brown macules on hands and arms –“Liver spots” Keratosis caused by hyperpigmentation

24. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skin Changes in Older Adult Seborrheic keratosis –Dark raised lesions Actinic keratosis –Reddish raised plaques on areas of high sun exposure can become malignant Skin tags Hair and nail growth decreases

25. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skin Changes in Older Adult Postmenopausal may develop facial hair over and under chin Hair grays due to reduction of melanocytes Nails may thicken, yellow, and peel

26. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Integumentary System Diagnostic Tests –Biopsy –Stains and cultures –Skin scraping –Patch test –Wood’s light examination