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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