chap 3

• Components of integumentary assessment

  • Skin
  • Hair
  • Nails
• Skin assessment


  • Inspect for skin color uniformity
  • Inspect for lesions
  • Palpate skin moisture and temperature
  • Palpate for turgor
  • Note for presence of edema

  
• Pallor


  Pale, white color caused by decrease of blood flow (vasoconstriction) or decrease in hemoglobin, shock, or anemia
• Erythema


  Redness due to increased blood flow (vasodilation) like in fever, inflammatory process, emotions, CO poisoning
• Cyanosis


  Bluish, purplish hue due to decreased perfusion of tissues maybe due to hypoxemia due to heart failure, shock or chronic bronchitis
• Jaundice


  Yellow, orange hue due to jaundice (increased bilirubin in blood) maybe due to liver problems such as hepatitis, cirrhosis
• Ecchymosis


  Collection of blood in the subcutaneous tissues causing purplish discoloration
• Petechiae


  Small hemorrhagic spots caused by capillary bleeding
• Primary skin lesions


  • Macule
  • Patch
  • Papule
  • Plaque
  • Nodule
  • Tumor
  • Pustule
  • Vesicle
  • Bulla
  • Cyst
  • Wheal

  
• Secondary skin lesions


  • Atrophy
  • Erosion
  • Lichenification
  • Ulcer
  • Fissure
  • Scar
  • Scales
  • Crust
  • Keloid
  • Excoriation

  
• Skin moisture and temperature can be normal or abnormal
• Skin turgor can be normal or abnormal

  
• Edema can be normal or abnormal
• Hair assessment


  • Inspect the evenness of growth over the scalp
  • Inspect hair volume
  • Inspect for texture and oiliness over the scalp
  • Note for presence of infection and infestations
  • Inspect amount of body hair
• Nail assessment


  • Inspect fingernail plate shape
  • Inspect tissues surrounding nails
  • Inspect for nail bed color
  • Perform blanch test of capillary refill

  
• Spoon nail


  Concave curvature of the nail plate

  
• Clubbing


  Increased curvature of the nail plate
• Paronychia


  Inflammation of the tissues surrounding the nail

  
• Capillary refill test can be normal or abnormal