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					INTEGUMENTARY
THE SKIN

Epidermis

Dermis
              Functions:
•   Protection
•   Sensation
•   Vitamin D Production
•   Temperature Regulation
•   Excretion
                  Dermis
      Consists of collagen and elastic fibers
  which are responsible for the structural
  strength

Subcutaneous Tissue (Hypodermis)
  Loose connective tissue that stores fat
Cells and cushions body
                 Epidermis
  Epithelial tissue that comprises the
outermost layer of skin

Keratinization is the maturation of epithelial cells

5 Layers:
Stratum Basale, Stratum spinosum,
Stratum Granulosum, Stratum Lucidum
And Stratum Corneum
        Layers of Epidermis
• Stratum Basale

 -New skin cells are formed

 - 25 % are melanocytes (within epithelial
 cells)
• Melanin production is detemined
  by:
  - genetic factors ( Albinism)
  - exposure to light
  - Hormones
  - blood flow
  GOLGI
APPARATUS
         Layers of Epidermis
• Stratum Corneum
  -most superficial
  -consist of dead, squamous cells filled with
  hard protein keratin (structural strength)
  -coated and surrounded by lipids (prevents
  fluid loss through the skin)
Accessory Skin Structures

     1. Hair
     2. Muscles
     3. Glands
     4. Nails
Hair
-Vellus Hair: fine, short
strands, grows in the
entire body
   Except: margins of lip,
   nipples, palms, soles,

-Terminal hair: darker,
coarser, and longer
(eyebrows and scalp)
Arrector pili:

-contraction
causes
Hair to become
perpendicular to
the
skin’s surface

- “goose Flesh”
GLANDS
Sebaceous Glands:
-simple branched
acinar glands
Sebum:oily white
substance rich in lipids

Sweat Glands :
Merocrine
Apocrine
Merocrine SG :
• located in almost part of the body
• secretions are mostly water with few
  salts, sweat pores

Epocrine SG
• axillae and genitalia
• active in puberty
• influence by hormones
• Bacteria = body odor
   SPECIAL
CONSIDERATIONS
                   Newborn
Vernix caseosa:
• white cheese like mixture of the sebum and
epidermal cells

Lanugo:
• fine, downy hair of newborn, replaced by vellus
hair in few months
Milia:
• tiny white facial papules due to sebum
  collection in opening of hair follicles
Stork bites:
• Due to dilatation of vessels patches on
  the back of the neck.
Infancy
  Harlequin color
  change :

  • side lying : pink on
  the dependent side
  and pale on the non
  dependent side.
                  Infancy

Mongolian spots:
  ACROCYANOSIS

• gray, blue or purple      MONGOLIAN SPOT

spots in the sacral
and buttocks of
newborn


   JAUNDICE
Physiologic
jaundice:
• yellowish
discoloration of
the skin, sclera,
mucous membrane
after 24 hours of
birth

• treated with
phototherapy
                Acrocyanosis
• Upper &/or lower
Extremities

• Within first hours of life
Pregnant
Gravidarum
Adolescent

- Hormonal changes causes
hyperactive sebaceous glands

- Acne
                   Elderly
Physiological change        Physical Findings

 ↓ SQ tissue             Thin flat skin

 Loss of collagen and    wrinkles
 elastic fibers
 ↑ Capillary fragility   purpuras

 ↓ sweat gland activity Xerosis (dry skin)

 Over exposure to sun Liver spots

 Loss of melanocytes     Liver spots
               Effects of Aging
• Thinning of skin layers

• Loss of elasticity

• Sagging/wrinkling

• Decreased subcutaneous fat
                  Effects of Aging

• Vascular fragility/increased bruising & purpura

• Diminished wound healing

• Diminished immune function/increased skin cancers

• Decreased sweat glands/dry skin

• Decreased ability to regulate temperature
Elderly: Seborrheic
keratoses

- Could be precancerous
                   PURPURA
                   Capillary Fragility



                             WRINKLES




                         LIVER SPOTS
              Liver spots (senile lentigo):
              Accumulated areas of
              pigmentation
LIVER SPOTS
Assessing Skin Turgor
               Assessment
Subjective data:
  General info and specific information:

• Possible causes – occupation, allergens, exposure
  history

• Medical history and family history (eczema)

• Alleviating factors – MD or self prescribed
• History of skin problem
 SWIPE:

          Start
          Worse
          Improve
          Pattern
          Evaluation
• Inspection then palpation

Wear gloves if contact with any secretion or
 blood.

• Systematic Head to toe

Skin assessment is integrated throughout the
  complete exam as you go through each body
  system or from head to toe fashion.
              Skin Assessment
Objective Data

  – Skin color               - Temperature and moisture
  (pink, pallor, jaundice,
  cyanosis, erythema)

  – General pigmentation     - Vascularity or bruising



  – Turgor and mobility      - Lesions
          Skin Assessment
• Objective data
  – Physical assessment

  – Inspection and palpation

  – Head to toe

  – Ensure good lighting and privacy

  – Draw picture or take photo if possible
Skin Lesions (Characteristics)
• TYPE (e.g. macule,      • DISTRIBUTION/
  papule, vesicle)        PATTERN
                             –E.g. generalized,
• COLOR                       diffuse, nerve
                              path, diaper area
• SIZE (L x W x D)
                          • ELEVATION/DEPRE
• SHAPE/                    SSION
CONFIGURATION
                          • EXUDATES
• TEXTURE                    –Amount, color,
                              consistency
                   Skin Lesion Types
• Type
- macule, papules, vesicle, nodule
• Size
– use metric system; measure with a ruler; Length x
  width, and depth cmx cm x cm

• Shape and configuration
- round, oval,
- linear (form a line), grouped (clustered)
• Texture
– rough, smooth
                      Skin Lesion Types
• Reaction to pressure
– blanching or remains the same

• distribution/pattern
– around jewelry, nerve path, diaper area, generalized all
  over body, diffuse all over one area of body

• Elevation- depression
 – raised, flat, depressed like a crater, circumscribed (can
   feel in between thumb and index finger)

• Exudate
– color, consistency, purulent, serous, serosanguinous
       Shapes and Configurations


                           Grouped:
                               Herpes
Individual:   Insect
              Bite
Confluent:                 Linear:
                           Dermatitis
         Exanthema
       Skin Lesions Types
• Primary: (Initial lesions) Appear in response to
  external or internal environment of skin.




                                Vesicle,
                                Bulla
               Lesion Type
• Primary Lesions: (Initial lesions)
Appear in response to external or internal
  environment of skin.

When lesions appear on previously unaltered
 skin

Ex.: Macules / patch, papule/plaque,
  nodule/tumor, wheal, urticaria (hives),
  vesicle/bulla, cyst, pustule
Primary Lesions

   • Macule – flat and
     circumscribed,
   • less than 1 cm (freakles,
     measles)


   • Patch – macules larger than
     1 cm (mongolian spots,
     vitiligo)
Primary Lesions
        • Papule – solid,
          elevated,
          circumscribed less
          than 0.5 cm (moles,
          warts)



        • Plaque – a papule that
          is wider than 0.5 cm
          (psoriasis)
Primary Lesions
    • Nodule – solid, elevated, hard
      or soft, about0.5 -2 cm (small
      lipoma)

    • Tumor – larger than 2 cm,
      hard or soft, deeper into the
      dermis; larger lipoma,
      hemangioma. May be
      malignant or benign.

    • Wheal – superficial raised
      and erythematous, slighly
      irregular shaped due to edema
      (swelling); mosquito bite,
      allergic reaction
Primary Lesions
          • Vesicle – elevated, contains
            serous fluid, less than 1 cm



          • Bulla – Contains fluid, more
            than 1 cm



          • Pustule – Pus filled, less than
            1 cm
Primary Lesions
              • Cyst – elevated, contains
                fluid or viscous matter,
                into dermis




              • Telangiectasia – Pus
                filled, less than 1 cm
Primary Lesions: Solid
       Primary Lesions: Fluid filled




Vesicle, Bulla
               Widespread Color Changes
                        Pallor
• Anemia
                                 • Observe mucous
• Shock                            membranes, lips, &
                                   nail beds
• Dietary Deficiencies

• Local Arterial Insufficiency

• Renal Failure

• Albinism
                    Widespread Color changes
                              Cyanosis
• Bluish mottled color, caused by hypoxia


   Central - chronic heart and lung disease

   Peripheral (nailbeds, earlobes)
   • vasoconstriction R/T exposure to cold, anxiety
   •venous insufficiency
           Widespread Color changes
                    Erythema

• Redness of skin related to capillary congestion from
  inflammation/infection


Light skin: red bright pink

Dark skin: purplish tinge but difficult to see:
 PALPATE FOR WARMTH
           Widespread Color changes

                    Jaundice
• Yellow color caused by increased levels
  of bilirubin in the blood.

• First noted in junction of hard/soft
  palate and in the sclera

• As bilirubin levels increase, jaundice is
  evident over rest of body.
Jaundice
    Light skin:
    yellow in sclera, hard palate,    mucous
    membranes, then over skin


     Dark skin:
     • check sclera for yellow
     • best noted in the junction of hard and soft
      palate and also palms
                   Skin Lesion Types


Secondary Lesions: Are a result of trauma, chronicity,
  or infection of primary lesion.

  Examples: crust, scale, erosion, fissure, ulcer, excoriation, scar,
  keloid, lichenification
             Skin Lesion Types
Secondary Lesions: Are a
  result of trauma,
  chronicity, or infection
  of primary lesion.
          Secondary Lesions
                         Scale
Crust




 Keloid
              Fissure

                        Lichenification
            Fungal Infections
• Ringworm – antifungals (clotrimazole
  cream) (transmitted by contact)

• athletes foot (tinea pedis), jockitch
            Signs to alert you for
           Malignant Melanoma !!!
DANGER SIGNS: ABCDE
• Asymmetry
• Border irregularity
• Color variation
• Diameter >6mm
• Elevation and Enlargement
Skin Lesions




           Kaposi’s
           sarcoma
Skin Lesions




      Cellulitis   Varicella
           Skin Lesions




           Lyme Disease
           Rash
Urticari
a
    Skin Lesions
                   Port-Wine Stain




Rash from
 Rubber
 Product
                          Skin Lesions




What type of work might
   this person do?

                               What might have caused
                                       this?
                       Skin Lesion Types
• Vascular Lesions: Appear as red pigmented lesion. Could
  be indicative of bleeding
  – Hemangiomas
      • port wine stain; strawberry mark-mature
        hemangioma

  – Telangiectasias
      • spider angioma with pregnancy or liver disease;
        venous lake
  –   Purpuric Lesions
      • Petechiae
      • Ecchymoses
      • purpura
Skin Lesions
      Vascular Lesions- Cont.
                  HEMANGIOMA
                                  Petechiae



TELANGIECTASIA                          Ecchymosis

                 Spider Angioma


                                        Venous Lake
Vascular Lesions: Purpura
       Pattern Injury from Physical Abuse
• Shape suggests the
  instrument or weapon
  that caused it
• History that does not
  match the severity or
  type of injury indicates
  abuse
• Scalding injury, belt
  marks, bite marks,
  cigarette burns,
  deformity from untreated
  fracture
Pattern Injuries
Pattern Injury: Distribution
    Assessment of the Hair
• Subjective data
                      • Scalp

• Objective Data
                      • Inspect for lesions,
  – Color, Texture
                        scaling, tenderness,
  – Distribution
                        and masses
  – Lesions (scalp)
  – Infestations
            Parasitic Infestations
                    Pediculosis           Scabies


Cause            lice                Itch mite


Symptom &        Head, body, pubic   Finger webs,
Areas affected   area                creases of abd,
                                     wrist, axilla,
                                     breasts
Treatment        Pyrethroid (Rid)    Lindane,
                                     pyrethroid
      Parasitic Infestations
TINEA CAPITIS   TINEA CORPORIS   TINEA PUBIS
               Infestations cont.
• Scabies
   – A contagious
     disease

  – Transmission: close
    and prolonged
    contact or infected
    bedding
         Infestations Cont.
• Scabies lesion
  distribution
    Assessment of the Nails:
Inspect & Palpate

• Shape / Contour

• Consistency

• Surrounding tissue

• Nail angles
                       Normal Nails
• Smooth

• Firm

• Translucent with pink nail bed

• Uniform thickness

• 160 degree nail angle

• Capillary Refill (1-2 seconds, 3-4 seconds on geriatric clients)
Nails




   Nail Psoriasis


   Bates, Barbara, MD. A Guide to Physical
   Examination and History Taking, fourth
   edition. J.B. Lippincott. 1987.
Nail Angle
THANK YOU!!!!

				
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posted:5/16/2012
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