Integumentary Pt Assessment

1200

Patient Assessment:Integumentary SystemJOAN DAVENPORT

HistoryPhysical Examination

InspectionPalpation

Assessment of Pressure UlcersAssessment of Skin TumorsAssessment of the Skin in Older

AdultsAssessment of the Skin in Children

objectivesBased on the content in this chapter, the reader should be able to:■ Identify the assessment skill necessary for the critical care nurse

to use when evaluating the health of a patient’s skin.■ Identify expected differences in skin color related to racial or

skin tone characteristics.■ Describe and recognize abnormal changes in skin color.■ Recognize and describe skin lesions resulting from increased

vascularity.■ Describe the significance of rashes related to infection or to

allergic reaction.■ Identify the pitting and nonpitting edema.■ Explain the cause of pressure ulcers and at least one scale used

to assess a patient for pressure ulcer development.■ Describe the features of malignant skin diseases.

chapter

51

The skin of a critically ill person is exposed to insultsranging from diminished blood flow and the resul-tant risk of pressure ulceration to rashes from hyper-

sensitivity drug reactions and opportunistic infections.There is often ample opportunity for the critical care nurseto assess the skin—the intimacy involved in providing careto someone who is critically ill, the relative level of undressof the patient, and the attention to detail implicit in criticalcare nursing make integument assessment an ongoing andvital process.

HISTORY

When caring for patients with skin disorders, it is importantto obtain information from the health history (Box 51-1).The information is useful in guiding the physical examina-tion and in determining appropriate interventions.

PHYSICAL EXAMINATION

The assessment techniques necessary for an evaluation ofthe integument involve inspection and palpation.

InspectionInspection of the general appearance of the skin includesassessment of color; determination of the presence oflesions, rashes, or increased vascularity; and assessmentof the condition of the nails and hair.

COLORSkin color is expected to be uniform over the body, exceptfor the areas with greater degrees of vascularity. The geni-talia, upper chest, and cheeks may appear pink or have a red-dish tone in people with light skin. These same areas mayappear darker in people with dark skin. Additional normalvariations in skin color include those listed in Table 51-1.

CHAPTER 51 Patient Assessment: Integumentary System 1201

Skin color is determined by the presence of four pig-ments: melanin, carotene, hemoglobin, and deoxyhemo-globin. The amount of melanin is genetically determinedand produces varying degrees of dark skin tone. Carotene,a yellow pigment, is in subcutaneous fat and is most evidentin those areas with the most keratin, the palms and soles ofthe feet. Skin color abnormalities, such as pallor, cyanosis,jaundice, and erythema, manifest differently depending onthe person’s normal skin tone (Table 51-2).

The degree of oxygenation affects skin color. Hemo-globin, attached to red blood cells, transports oxygen tothe tissues. A diminished flow of oxyhemoglobin throughthe cutaneous circulation results in pallor. In people withlight skin, the skin appears very pale, without the usual

pink undertones. In people with darker skin, pallor mani-fests as a yellowish-brown or ashen appearance (again,because the usual pink undertones are lost).

As hemoglobin gives up its oxygen to the tissues, thehemoglobin changes to deoxyhemoglobin. When deoxyhe-moglobin is present in the cutaneous circulation, the skintakes on a blue cast and the individual is said to be cyanotic.1In light-skinned people, cyanosis may be seen as a grayish-blue color, especially in the palms and soles of the feet, thenail beds, the earlobes, the lips, and the mucous mem-branes. In those with darker skin, cyanosis evidences itselfas an ashen-gray color seen easiest in the conjunctiva, oralmucous membranes, and nail beds.2

The yellowish hue of jaundice is indicative of liver dis-ease or of hemolysis of red blood cells. In dark-skinnedpeople, jaundice is seen as a yellowish-green color in thesclera, palms of the hands, and soles of the feet. In light-skinned people, jaundice is seen as a yellow coloration ofthe skin, sclera, lips, hard palate, and underside of thetongue. Bickley and Szilagyi recommend using a trans-parent slide pressed against the lips to “blanch out the redcolor,” making the yellow of jaundice more easily seen.1

Another skin color abnormality is erythema. Erythemamanifests as a reddish tone in light-skinned people and adeeper brown or purple tone in dark-skinned people. It isindicative of increased skin temperature caused by inflam-mation. The process of inflammation increases vascularityof the tissues and this, in turn, produces the color alterationseen with erythema. Erythema may be expected when asso-ciated with a surgical wound, due to the inflammatory pro-cess inherent in any tissue trauma. It is also seen in diseaseprocesses affecting the skin, such as cellulitis. In either case,the erythema is indicative of inflammation.

LESIONSSkin lesions are variously described by their color, shape,cause, or general appearance (Table 51-3). They are con-sidered abnormal conditions and arise from many factors.In general, it is important to note the anatomical location,distribution, color, size, and pattern of any abnormal skinlesion. In addition, details about the lesion’s borders oredges, as well as whether the lesion is flat, raised, or sunken,should be noted. Finally, the length of time the lesion has

box 51-1Patient History—Skin Disorders

Patient history relevant to skin disorders may beobtained by asking the following questions:When did you first notice this skin problem? (Also investi-

gate duration and intensity.)Has it occurred previously?Are there any other symptoms?What site was first affected?What did the rash or lesion look like when it first

appeared?Where and how fast did it spread?Do you have any itching, burning, tingling, or crawling

sensations?Is there any loss of sensation?Is the problem worse at a particular time or season?How do you think it started?Do you have a history of hay fever, asthma, hives,

eczema, or allergies?Who in your family has skin problems or rashes?Did the eruptions appear after certain foods were eaten?

Which foods?When the problem occurred, had you recently consumed

alcohol?What relation do you think there may be between a spe-

cific event and the outbreak of the rash or lesion?What medications are you taking?What topical medication (ointment, cream, salve) have

you put on the lesion (including over-the-counter medications)?

What skin products or cosmetics do you use?What is your occupation?What in your immediate environment (plants, animals,

chemicals, infections) might be precipitating this disorder? Is there anything new, or are there anychanges in the environment?

Does anything touching your skin cause a rash?How has this affected you (or your life)?Is there anything else you wish to talk about in regard to

this disorder?

From Smeltzer SC, Bare BG: Brunner: Suddarth’s Textbook of Medical–Surgical Nursing (10th Ed), p 1645. Philadelphia, LippincottWilliams & Wilkins, 2004.

table 51-1 ■ Normal Variations in Skin Color

Normal Variation Description

Moles (pigmented nevi)

Stretch mark (striae)

Freckles

Vitiligo

Birthmarks

Tan to dark brown; may be flat orraised

Silver or pink; may be caused byweight gain or pregnancy

Flat macules anywhere on the body

Unpigmented skin area; moreprevalent in people with dark skin

Generally flat marks anywhere onthe body; may be tan, red, orbrown

1202 PART 11 INTEGUMENTARY SYSTEM

table 51-2 ■ Skin Color Abnormalities

Skin Color Manifestation in Manifestation inAbnormality Underlying Cause Light-Skinned People Dark-Skinned People

Pallor

Cyanosis

Jaundice

Erythema

Decreased blood flow(decreased oxyhemo-globin flow to tissues)

Increased deoxyhemoglo-bin in the cutaneous circulation

Increased red blood cellhemolysis, liver disease

Inflammation

Excessively pale skin

Grayish-blue color of the palms and solesof the feet, the nailbeds, the lips, the ear-lobes, and the mucousmembranes

Yellow color of the sclera,lips, and hard palate

Reddish tone

Yellowish-brown or ashencolor to the skin

Ashen-gray color of theconjunctiva, oralmucous membranes,and nail beds

Yellow-green color of thesclera and palms andsoles of the feet

Deeper brown or purpletone

table 51-3 ■ Types of Skin Lesions

Lesion Description

Blister

Bulla

Comedo

Crust

Cyst

Desquamation

Erosion

Excoriation

Fissure

Macule

Nodule

Papule

Plaque

Pustule

Scale

Tumor

Ulceration

Urticaria

Vesicle

Wheal

From Allwood, Curry. 2000.

Fluid-filled vesicle or bulla

Blister larger than 1 cm

Plugged and dilated pore, called blackhead or whitehead

Dried exudate over a damaged epithelium; may be associated with vesicle, bullae,or pustules

Semisolid or fluid-filled mass, encapsulated in deeper layers of skin

Shedding or loss of debris on skin surface

Loss of epidermis; may be associated with vesicles, bullae, or pustules

Epidermal erosion usually caused by scratching

Crack in the epidermis usually extending into the dermis

Flat area of skin with discoloration, less than 5 mm in diameter

Solid, elevated lesion or mass, 5 mm to 5 cm in diameter

Solid, elevated lesion less than 5 mm in diameter

Raised, flattened lesion greater than 5 mm in diameter

Papule containing purulent exudate

Skin debris on the surface of the epidermis

Solid mass, larger than 5 cm in diameter; usually extends to dermis

Loss of epidermis, extending into dermis or deeper

Raised wheal-like lesion

Small fluid-filled lesion, less than 1 cm in diameter

Transient, irregular pink elevation with surrounding edema


been present, and any environmental or medication expo-sure that may be considered contributory, are also noted.3

Vascular lesions can be either a normal variation or anabnormal finding. Vascular changes considered to be nor-mal variants include nevus flammeus (port-wine stain),immature hemangioma (strawberry mark), telangiectasis,cherry angioma, and capillary hemangioma (Table 51-4).Abnormal vascular findings include petechiae, purpura,ecchymoses, spider angiomas, and urticaria (hives). Thesefindings may indicate disease or injury and warrant furtherinvestigation by the critical care nurse.

Petechiae are purple or red, small (1- to 3-mm) lesionseasily seen on light-skinned individuals and more difficultto see in those with dark skin (Fig. 51-1A). They may beseen on the oral mucosa and in the conjunctiva. They donot disappear when pressure is applied to them.2 Petechiaeresult from tiny hemorrhages in the dermal or submucosallayers. Purpura are very similar to petechiae, only larger.Purpura may appear brownish-red.

Ecchymoses are bruises. They may appear as purpleto yellowish-green rounded or irregular lesions, and aremore easily seen in people with light skin (see Fig. 51-1B).Ecchymoses occur as a result of trauma, when blood leaksfrom damaged blood vessels into the surrounding tissue.

Spider angiomas are fiery red lesions that are mostoften located on the face, neck, arms, or upper trunk (seeFig. 51-1C). Spider angiomas are seldom seen below thewaist. They have a central body that is sometimes “raisedand surrounded by erythema and radiating legs.”1 Theselesions are most often associated with liver disease andvitamin B deficiency.2

Urticaria is a reddened or white, raised, nonpittingplaque that often occurs as a result of an allergic reaction.The lesion often changes shape and size during the courseof the reaction. The edema associated with urticaria is aresult of local vasodilation and inflammation, which isfollowed by transudation of serous vascular fluid into thesurrounding tissue.

RASHESRashes identified during inspection may indicate infectionor a reaction to drug therapy. Some of these rashes areidentified by the names listed in Table 51-3. Identifyingthe type of lesion may help in identifying the cause of the

rash. Attention to the development of a rash in associationwith a change in pharmacotherapy is essential to help iden-tify the occurrence of an allergic hypersensitivity reaction.The development of urticaria is often associated with foodor drug reactions. Urticaria usually resolves completelyover days to several weeks as the excess local fluid is re-absorbed. These lesions are often pruritic, and patientscratching may precipitate secondary skin abrasions, whichcan place the patient at risk for localized skin infections.

Skin infections are most often caused by fungi or yeasts,and may range from superficial tinea pedis (athlete’s foot)to intermediate yeast infections (e.g., moniliasis resultingfrom Candida albicans infection) to deep fungal infections(e.g., aspergillosis) that invade the underlying tissues. Mostoften in the critical care setting, fungal and yeast infec-tions are of the intermediate type and are the result of anopportunistic infection by normal flora. Antibiotics andcorticosteroids place the patient at risk for these infections.Candidiasis presents in the groin and under the breasts offemale patients with “erythema, a whitish pseudomembrane,and peripheral papules and pustules.” Oral candidiasis,also known as thrush, manifests as a whitish coating of theoral mucosa, especially the tongue. This painful conditionmay produce fissures on the tongue and often restricts apatient’s oral intake, further compromising the patientfrom a nutritional perspective.

CONDITION OF THE HAIRThe patient’s terminal hair is inspected daily, noting thehair’s quantity, distribution, and texture. Scalp hair shouldbe resilient and evenly distributed.

Alopecia refers to hair loss and can be diffuse, patchy,or complete. Hair loss in the critical care setting can beassociated with pharmacotherapy. Chemotherapy used inoncology treatment produces alopecia. Other drugs, suchas heparin, used for a prolonged time may also be respon-sible for hair loss.6 Hirsutism or increased facial, body, orpubic hair growth is an abnormal finding in the examina-tion of women and children. Hirsutism has a familial pat-tern and is associated with menopause, endocrine disorders,and certain pharmacotherapies (e.g., corticosteroids andandrogenic medications).2

A change in the hair’s texture may indicate ongoinghealth concerns. Hair that is thin and brittle occurs in

table 51-4 ■ Vascular Lesions: Normal Variations

Normal Variation Description

Nevus flammeus (port-wine stain),immature hemangioma(strawberry mark)

Cherry angioma

Capillary hemangioma

Telangiectasis

Range from dark red to pale pink in color and are consideredbirthmarks

Small, slightly raised, bright red lesions on the face, neck, andtrunk; increase in size and number with advancing age

Red, irregular patch caused by capillary dilation in the dermis ofthe skin

Irregular, fine red lines caused by permanent dilation of a groupof superficial vessels

hypothyroidism. In those with severe protein malnutri-tion, the hair color may appear reddish or bleached andthe hair texture is described as coarse and dry.7

Also not to be overlooked is the presence of infectionor infestation of the scalp and hair. The patient’s scalp andbody hair is inspected regularly for evidence of flaking,sores, lice, louse eggs, and ringworm.7 During the inspec-tion, the hair is parted in several areas to reveal the under-lying scalp.

CONDITION OF THE NAILSNails, like hair, can be overlooked in the rush of criticalcare nursing; however, a careful inspection as part of the“routine” assessment can reveal information about thepatient’s general state of health. The nail bed is very vas-cular and is an excellent location for assessing the ade-quacy of the patient’s peripheral circulation. The capillaryrefill test, done by blanching the nail beds and then releas-ing the pressure, should indicate a return of the pink tonesin less than 3 seconds. Nail beds that are bluish or purplishin tint may be indicative of cyanosis; nail beds that are palemay indicate reduced arterial blood flow.

When the angle of the nail is 180 degrees or greater,clubbing is said to be present (see Chapter 24, Fig. 24-2).Clubbing is attributed to chronic hypoxemia. Other shapesthat the nail takes on may provide clues to deficient nutri-tional states of the patient. Chronic disease states such ascirrhosis, heart failure, and type 2 diabetes mellitus mayaffect the nails by producing Terry’s nails.1 These nails arewhitish with a distal band of dark reddish-brown color,and the lunulae may not be visible (Fig. 51-2). A spoon-shaped nail, called koilonychias, is associated with iron-deficiency anemia. Bands across the nails, especially in theolder adult, may indicate protein deficiency. White spotson the nails are associated with zinc deficiency.7

PalpationThe skin is palpated for texture, moisture, temperature,mobility and turgor, and edema. In addition, during pal-pation any evidence of discomfort arising from the areaspalpated is noteworthy.

TEXTURETexture refers to the smoothness of the skin surface. Itrequires gentle palpation to assess. Rough skin occurs inpatients with hypothyroidism.

MOISTUREThe skin may be described as dry, oily, diaphoretic, orclammy. Dry skin may be seen in the patient with hypo-thyroidism. Skin is oily with acne and with increasedactivity of the sebaceous glands, as in Parkinson’s disease.Diaphoresis may be a response to increased temperatureor increased metabolic rate. Hyperhidrosis is the term givento excessive perspiration. Bromhidrosis refers to foul-smellingperspiration. Low cardiac output states may produce skinthat is referred to as clammy.

TEMPERATURETemperature is usually assessed with the dorsal surface ofthe hand to identify the general skin temperature as warmor cool. The skin’s temperature can also be used to assessthe possibility of reduced blood flow from an arterial insuf-ficiency. In this case, the skin may be noticeably cooler dis-tal to an occluding lesion.

MOBILITY AND TURGORMobility and turgor provide information about the healthof the skin and may yield information about the patient’sfluid volume balance. When assessed centrally, over theclavicles, the skin is expected to lift up easily and quicklyreturn into place. Skin mobility may be decreased in scle-roderma or in a patient with increased edema. Skin turgoris decreased in the patient with dehydration.1


figure 51-1 Abnormal vascular lesions. (A, used with permissionfrom Kelley WN: Textbook of Internal Medicine. Philadelphia, JBLippincott, 1989. B, used with permission from Bickley L: Bates’Guide to Physical Examination and History Taking [8th Ed], p 106.Philadelphia, Lippincott Williams & Wilkins, 2003. C, used with per-mission from Marks R: Skin Disease in Old Age. Philadelphia, JB Lip-pincott, 1987.)

A. Petechiae/purpura B. Ecchyrriosis

C. Spider angioma

figure 51-2 Terry’s nails, seen in people with chronic diseasessuch as cirrhosis, congestive heart failure, and type 2 diabetes mel-litus. (Used with permission from Bickley L: Bates’ Guide to Physi-cal Examination and History Taking [8th Ed], p 110. Philadelphia,Lippincott Williams & Wilkins, 2003.)


EDEMAEdema is classified as either nonpitting or pitting. Nonpit-ting edema is that which does not depress with palpation.Nonpitting edema is seen in patients with a local inflam-matory response and is caused by capillary endothelialdamage. In addition to the edema, the skin is usually red,tender, and warm. Pitting edema is usually in the skin ofthe extremities and in dependent body parts. Pitting edemais identified as edema that retains the depression madewhen palpated. This type of edema can be further classi-fied by the depth of the depression and, occasionally, by theamount of time it takes the pit to rebound (Table 51-5).

ASSESSMENT OF PRESSURE ULCERS

The development of pressure ulcers in the critically illpatient is a preventable complication. The difficulty arisesin the patient with multiple-system dysfunction with con-comitant fluid, electrolyte, and nutritional deficiencies.Common pressure ulcer points include the occiput, scapula,sacrum, buttocks, ischium, heels, and toes. It is the pressureapplied by the weight of the body that causes a reduction inarterial and capillary blood flow, leading to these ischemicevents. Therefore, frequent position changes are requiredto prevent the development of pressure ulcers. Pressureulceration on the toes occurs as a result of the pressure ofthe bed linen on the feet. Dressing devices and woundappliances can place pressure on underlying skin, result-ing in reduced blood flow. The back of the neck of thepatient with a tracheostomy tube must be assessed becausethe tube holder may be applied too tightly. The tape secur-ing a nasogastric tube must be regularly removed and thecondition of the tip of the nose and nares assessed forchanges resulting from pressure from the tube.

Assisting the patient with frequent position changes iscrucial in preventing pressure ulcers from developing. Inaddition, keeping the skin clean and dry is requisite in theprevention of pressure ulceration. Moisture increases therisk for maceration of the skin and promotes its breakdown.Infectious matter in wound drainage or feces increases therisk that an ulcer will progress and become a major sourceof sepsis.

Patients with decreased sensation (e.g., from brain orspinal cord injury or from a peripheral neuropathy such asthat caused by diabetes) are at greater risk for ulceration

because they do not recognize the discomfort from beingin one position for extended periods. Similarly, patientswith sedation or frequent analgesic dosing are at increasedrisk for problems related to their immobility. Patientswith poor circulation, such as that caused by hypotension,heart failure, or peripheral vascular insufficiency, are alsoat higher risk because of the underlying possibility of tis-sue hypoxia. Lack of movement then serves only to accel-erate the process of pressure ulcer development.

Identifying those individuals most at risk for pressureulcer development is a focus of assessment. Recognizingthat there are certain features that increase a patient’s riskfor development of pressure ulcers allows the critical carenurse to increase surveillance and implement preventa-tive treatment modalities. Problems with sensory percep-tion, moisture, activity, mobility, nutrition, and frictionand shearing forces increase the patient’s risk for develop-ment of pressure ulcers, which are debilitating and expen-sive to treat. Critically ill patients are among those with themost significant limitations of these parameters, and there-fore are at very high risk for the development of pressureulcers.

Many tools for assessing pressure ulcer risk use a pointsystem.8,9 The Braden Scale for Predicting Pressure SoreRisk, recommended in the guidelines set forth by the U.S.Agency for Health Care Policy and Research and widelyused in hospital settings, requires the daily assessment ofsix parameters and provides a numerical score rangingfrom a very high risk score of 6 to a very limited risk orminimal risk score of 2310 (Fig. 51-3). Adults with a scorebelow 16 (18 for older adults) are considered at risk andspecific interventions to prevent the development of ulcer-ation are recommended. There has been some work doneto establish the relative risk among those with darker-pigmented skin using a higher cut-off score of 18.11 A 2002study by Bergstrom and Braden compared cut-off scoresfor black and white populations and found no differencebetween scores, but a score of 18 best predicts pressureulcer risk for both groups.12

During assessment of the skin, the nurse must be vigi-lant for signs of skin breakdown (Fig. 51-4).

ASSESSMENT OF SKIN TUMORS

Benign nevus and seborrheic keratosis are common, benignskin lesions. The benign nevus or mole appears in the firsttwo to three decades and its appearance remains unchanged

table 51-5 ■ Pitting Edema Scale

Scale (1+ to 4+) Measurement Description Time to Rebound

1+/4 2 mm Barely detectable Immediate

2+/4 4 mm Deeper pit Few seconds

3+/4 6 mm Deep pit 10–20 sec

4+/4 10 mm Very deep pit > 20 sec

over time. These lesions have clearly defined borders, areuniform in color, and round or oval in shape. The nevus isperiodically assessed for changes because a change mayindicate dysplasia of the tissue and the risk of melanoma.Seborrheic keratoses are common, yellow to brown lesionsthat are described as velvety when touched1 (Fig. 51-5A).These lesions are often multiple and often symmetrically

distributed on the trunk and face. Precancerous lesions(actinic keratoses) are thick, rough patches that develop onsun-exposed areas of the skin, especially in fair-skinnedpeople (see Fig. 51-5B). They are described as “white, scalykeratotic (horny) lesions on the exposed areas of the body.”These lesions require attention because there is a risk fordevelopment of squamous cell carcinoma.4


Braden Scale

FOR PREDICTING PRESSURE SORE RISK Patient's Name Evaluator's Name

SENSORY PERCEPTION 1. Completely Limited: 2. Very Limited: 3. Slightly Limited: 4. No Impairment: Unresponsive (does not Responds only to painful Responds to verbal com- Responds to verbal com- Ability to respond meaning- moan, flinch, or grasp) to stimuli. Cannot communicate mands, but cannot always mands. Has no sensory deficit fully to pressure-related painful stimuli, due to discomfort except by moaning communicate discomfort or which would limit ability to feel discomfort diminished level of con- or restlessness. need to be turned. or voice pain or discomfort. sciousness or sedation. OR OR OR has a sensory impairment has some sensory impairment limited ability to feel pain which limits the ability to feel which limits ability to feel over most of body surface. pain or discomfort over 1/2 pain or discomfort in 1 or 2 of body extremities.

MOISTURE 1. Constantly Moist: 2. Very Moist: 3. Occasionally Moist: 4. Rarely Moist: Skin is kept moist almost Skin is often, but not always, Skin is occasionally moist, Skin is usually dry, linen only Degree to which skin is constantly by perspiration, moist. Linen must be changed requiring an extra linen change requires changing at routine exposed to moisture urine, etc. Dampness is at least once a shift. approximately once a day. intervals. detected every time patient is moved or turned.

ACTIVITY 1. Bedfast: 2. Chairfast: 3. Walks Occasionally: 4. Walks Frequently: Confined to bed Ability to walk severely limited Walks occasionally during day, Walks outside the room at least Degree of or nonexistent. Cannot bear but for very short distances, twice a day and inside room at physical activity own weight and/or must be with or without assistance. least once every 2 hours assisted into chair or wheel- Spends majority of each shift during waking hours. chair. in bed or chair.

MOBILITY 1. Completely Immobile: 2. Very Limited: 3. Slightly Limited: 4. No Limitations: Does not make even slight Makes occasional slight Makes frequent though slight Makes major and frequent Ability to change and changes in body or extremity changes in body or extremity changes in body or extremity changes in position without control body position position without assistance. position but unable to make position independently. assistance. frequent or significant changes independently.

NUTRITION 1. Very Poor. 2. Probably Inadequate: 3. Adequate: 4. Excellent: Never eats a complete meal. Rarely eats a complete meal Eats over half of most meals. Eats most of every meal. Usual food intake pattern Rarely eats more than 1/3 of and generally eats only about Eats a total of 4 servings of Never refuses a meal. Usually any food offered. Eats 2 1/2 of any food offered. protein (meat, dairy products) eats a total of 4 or more servings or less of protein Protein intake includes only 3 each day. Occasionally will servings of meat and dairy (meat or dairy products) per servings of meat or dairy refuse a meal, but will usually products. Occasionally eats day. Takes fluids poorly. products per day. Occasionally take a supplement if offered. between meals. Does not Does not take a liquid dietary will take a dietary OR require supplementation. supplement. supplement. is on a tube feeding or TPN OR OR regimen which probably meets is NPO and/or maintained on receives less than optimum most of nutritional needs. clear liquids or IVs for more amount of liquid diet or tube than 5 days. feeding.

FRICTION AND SHEAR 1. Problem: 2. Potential Problem: 3. No Apparent Problem: Requires moderate to Moves feebly or requires Moves in bed and in chair maximum assistance in minimum assistance. During independently and has moving. Complete lifting a move skin probably slides to sufficient muscle strength to lift without sliding against sheets some extent against sheets, up completely during move. is impossible. Frequently chair, restraints, or other Maintains good position in bed slides down in bed or chair, devices. Maintains relatively or chair at all times. requiring frequent repositioning good position in chair or bed with maximum assistance. most of the time but occasion- Spasticity, contractures or ally slides down. agitation leads to almost constant friction.

Braden Scale Scores Total Score 1 = Highly Impaired NPO: Nothing by Mouth 3 or 4 = Moderate to Low Impairment Total Points Possible: 23 IV: Intravenously Risk Predicting Score: 16 or Less TPN: Total parenteral nutrition

Date ofAssessment

figure 51-3 The Braden Scale is a widely used screening tool to identify people at risk for pressure ulcers.(Courtesy of Barbara Braden and Nancy Bergstrom. Copyright, 1988. Reprinted with permission.)

1 LINE


Skin cancer is the most common type of cancer in theUnited States. It is estimated that 40% to 50% of thosewho live to age 65 years will be diagnosed with skin cancerat least once.14 Basal cell and squamous cell cancers areoften grouped as nonmelanoma skin cancers. Basal cellcarcinomas are found exclusively in light-skinned people,and arise from the hair follicles on the head and neck. Pro-longed and cumulative exposure to the sun is recognizedas the cause of basal cell carcinoma. These tumors are slowgrowing and rarely metastasize but do cause local skindestruction and disfigurement. Basal cell carcinomas appearwith pearly borders, depressed centers, and rolled edges3,13

(see Fig. 51-5C).Squamous cell carcinomas affect the skin and the mucous

membranes. Like basal cell cancers, the primary cause isexposure to ultraviolet light. Radiation and tissue damagefrom scars, ulcers, and fistulas may give rise to squamouscell carcinomas. These cancers can be invasive and are moremalignant than basal cell cancers if not treated promptly. Asit develops, the carcinoma takes on a hyperkeratotic appear-ance and may ulcerate and bleed3 (see Fig. 51-5D).

Malignant melanomas are highly metastatic lesionsthat come from the melanin-producing cells of the body.The worldwide frequency of malignant melanomas isgrowing more rapidly than any other cancer except lungcancer. Those at highest risk include those with fair com-

plexions, those prone to sunburn, and those with a familyhistory of melanoma.14 The most common location for thedevelopment of these lesions is on the trunk in men and onthe legs in women. The tumors have irregular borders, aredark brown or black, and are usually larger than 6 mm. TheAmerican Cancer Society (ACS) recommends a monthlyself-assessment for melanoma using the “ABCDs.”15 A isfor asymmetry; B is for borders (are they irregular, ragged,notched, or blurred?); C is for color (dark brown or black,red, white, or blue?); and D is for diameter.

Figure 51-5 provides pictures and descriptions of thesebenign, premalignant, and malignant lesions. While in acritical care setting, it is possible to do a thorough assess-ment for suspect skin lesions that may be cancerous, referthe patient to a dermatologist or oncologist, and havetreatment initiated much sooner than would otherwisebe the case.

ASSESSMENT OF THE SKIN INOLDER ADULTS

With aging there are some expected changes to the integu-ment (Box 52-2). With loss of underlying fat tissue anddecreased vascularity of the dermal layer, the skin thins,

figure 51-4 Stages of pressure ulcers. (Used with permission from Weber J, Kelley J: Health Assessment inNursing [2nd Ed], p 133. Philadelphia, Lippincott Williams & Wilkins, 2003. Illustrations used with permissionfrom Makelbust J, Sieggreen MY: Pressure Ulcers: Guidelines for Prevention and Management. Springhouse, PA,Springhouse, 2001.)

LONG


figure 51-5 Benign, premalignant, and malignant skin lesions. (A, B, and D courtesy of Sauer GC: Manual of SkinDiseases [5th Ed]. Philadelphia, JB Lippincott, 1985. C, Bickley L: Bates’ Guide to Physical Examination and HistoryTaking [8th Ed], p 107. Philadelphia, Lippincott Williams & Wilkins, 2003. E, American Cancer Society.)

A. Seborrheic Keratosis B. Actinic Keratosis C. Basal Cell Carcinoma

D. Squamous Cell Carcinoma E. Malignant Melanoma

box 51-2

Expected Changes in the Integument of Older Patients

■ Loss of underlying fat tissue and decreased vascularity ofthe dermal layer lead to thinning of the skin, increasedwrinkling, loss of skin turgor, and actinic purpura.

■ Sun exposure over a long period of time leads to yel-lowing and thickening of the skin and the developmentof solar lentigo.

■ Decreased sebaceous and sweat gland activity leads todry and flaking skin.

■ Decreased melanin leads to graying of the hair.■ Reduced hormone levels lead to thinning of the hair

and transition from terminal to vellus hair.■ Decreased peripheral circulation leads to slowed nail

growth and brittle nails that split easily.

wrinkles, and loses turgor. Prolonged or repeated sun expo-sure results in a yellowed or thickened appearance. Purplepatches or macules from blood leaking into the tissues afterminimal injury may appear. These lesions are called actinicpurpura and occur because the underlying capillaries losethe protection from hypodermal fat. Dry and flaking skinresults from decreased sebaceous and sweat gland activityand is not unexpected in the older adult patient.1,2 Solarlentigo, sometimes called “liver spots,” appear as light to

dark brown, flat macules and may be seen in isolation or inclusters on sun-exposed areas of the face or hands.4

In the older adult, hair color often transitions to graybecause of diminished melanin. Reduced hormone levelsresult in a change in the size of the hair follicle and pro-duce the change from coarse terminal hair to softer vellushair and the thinning of hair seen in both sexes. However,the opposite change, from vellus to terminal, occurs in thehair of the nares and on the tragus of men’s ears.2

Decreased peripheral circulation produces changes inthe nails. They grow more slowly but are often thicker andmore brittle, and have a tendency to split into layers. Mobil-ity restrictions over time may result in an unkempt appear-ance of nails in the older patient and may require attentionand care by a podiatrist.

The risk of pressure ulcer formation in the older adultis increased because of greater mobility limitations andimpaired peripheral circulation from cardiovascular, neuro-logical, and metabolic disorders. Once developed, pressureulcers in this population heal more slowly and are oftencomplicated by the older patient’s diminished immuneresponse.

ASSESSMENT OF THE SKIN IN CHILDREN

The assessment of a child’s skin is much the same as that ofan adult’s, but it is important to recognize that some find-ings take on a different significance because of the nature of


the child’s skin. Normally, the skin of a child is soft, smooth,and slightly dry. Skin that is locally very dry may indicateeczema, cradle cap, or diaper rash. Skin that is excessivelydry throughout the body may indicate a vitamin A defi-ciency or may be related to frequent bathing.16

Because of reduced total sun exposure, dark lesions,considered an expected finding in an older adult, may indi-cate a malignant change in a child. Bruises in a child mayindicate nonaccidental trauma and attention is paid to thelocation of the bruises and to the color. As a bruise ages,it changes color from purplish to greenish. The criticalcare nurse must be sure that special attention is paid to theskin of children in critical care settings related to lesionsfrom infectious disease; the skin is assessed for any rashesthat may indicate bacterial or viral infection.

clinical applicability challenges

Self-Challenge: Critical ThinkingMrs. Louise Hooper, a 62-year-old widow, has been inthe medical-surgical intensive care unit (ICU) for the past2 weeks after a diagnosis of respiratory failure and pneu-monia. This patient’s medical history includes obesity, type2 diabetes mellitus, and chronic obstructive pulmonary dis-ease (COPD). She has been intubated and on mechanicalventilation. She has received continuous enteral feed-ings through a nasogastric tube, numerous antibiotics, anddopamine for blood pressure support during her first 3 daysin the ICU. She has a triple-lumen central venous accesscatheter.

Mrs. Hooper is scheduled for a tracheostomy tomorrowand, at that time, will also have a percutaneous gastric feed-ing tube inserted. She has a continuous bladder catheter andan incontinence fecal bag in place draining liquid stool.Over the past 5 days, Mrs. Hooper has received a benzodi-azepine for sedation at least once per day. Physical ther-apy consultation was made on day 3, and she is assistedby two caregivers with a pivot to a chair twice each day.Mrs. Hooper’s family visits daily and helps her to commu-nicate with a pencil and paper tablet.1. What is the role of the critical care nurse in the prevention

of pressure ulcers for Mrs. Hooper?2. What are Mrs. Hooper’s risk factors for development of

pressure ulcers?3. How might the medications indicated (dopamine, numerous

antibiotics, and benzodiazepine sedation) affect Mrs. Hooper’sintegument status?

Study Questions1. The color change of erythema is related to

a. increased oxyhemoglobin content.b. increased tissue vascularity.c. decreased hemoglobin levels.d. decreased interstitial pressures.

2. Urticaria is best described as aa. purple, irregular lesion caused by tissue trauma.b. fiery red, raised lesion with a central body and radiat-

ing legs.

c. reddened or white, raised inflamed lesion with transu-date vascular fluid in the surrounding tissue.

d. small, pinpoint, nonblanching lesion.3. Which one of the following statements about oral candidiasis

is true?a. It is a painless manifestation of an opportunistic infection.b. It manifests itself as a white, crusty lesion of the patient’s

lips and hard palate.c. It is a painful white coating of the oral mucosa and

tongue.d. It is the result of systemic Staphylococcus infection.

4. Skin turgor is best assesseda. peripherally over the patient’s forearms and shins.b. peripherally at the nail beds.c. centrally over the trunk.d. centrally over the patient’s clavicles.

5. Which of the following phrases describes basal cell carci-noma?a. Depressed center, rolled edge, pearly borderb. Scaly white lesionc. Large, dark black lesion with irregular borderd. Light brown lesion that feels velvety when touched

6. Cyanosis in an African-American patient can best be identi-fied by assessment of thea. palms of the hands and soles of the feet.b. earlobes.c. conjunctiva and oral mucous membranes.d. dorsal surface of the forearm.

REFERENCES1. Bickley LS, Szilagyi PG: The skin. In Bickley LS (ed): Guide to

Physical Examination and History Taking (8th Ed), pp 95–113.Philadelphia, Lippincott Williams & Wilkins, 2003

2. Wilson SF, Giddons JF: Skin, hair, and nails. In Wilson SF, Gid-dons JF (eds): Health Assessment for Nursing Practice (2nd Ed),pp 257–287. St. Louis, Mosby, 2002

3. Allwood J, Curry K: Normal and altered functions of the skin. InBullock BA, Henze RL (eds): Focus on Pathophysiology, pp 837–873,Philadelphia, Lippincott Williams & Wilkins, 2000

4. American Academy of Dermatology: Agingskinnet. In Skincarephysicans.com. 2000. Available at http://www.skincarephysicians.com/agingskinnet/Q&A. Accessed July 1, 2003

5. Stawiski MA, Price SA: Cutaneous infections. In Price SA, WilsonLM (eds): Pathophysiology (6th Ed), pp 1087–1096. St. Louis,Mosby, 2003

6. Buttry TS: Anticoagulant and antiplatelet drugs. In Gutierrez K (ed):Pharmacotherapeutics: Clinical Decision-Making in Nursing, pp 774–789. Philadelphia, WB Saunders, 1999

7. Kozier B, Erb G, Berman AJ, et al: Health assessment. In Kozier B,Erb G, Berman AJ, et al. (eds): Fundamentals of Nursing (6th Ed),pp 531–629. Upper Saddle River, NJ, Prentice-Hall, 2000

8. Bergstrom N, Braden BJ, Laguzza A, et al: The Braden Scale forpredicting pressure sore risk. Nurs Res 36:205–210, 1987

9. Gosnell DJ: An assessment tool to identify pressure sores. Nurs Res22(1):55, 1973

10. Agency for Health Care Policy and Research, Panel for the Predic-tion and Prevention of Pressure Ulcers in Adults: Pressure Ulcers inAdults: Prediction and Prevention. Clinical Practice Guideline no. 15,AHCPR publication no. 92-0047. Rockville, MD: Agency for HealthCare Policy and Research, Public Health Service, U.S. Departmentof Heath and Human Services, 1992

11. Lyder CH, Yu C, Emerling J, et al: The Braden Scale for pressureulcer risk: Evaluating the predictive validity in black and Latino/Hispanic elders. Appl Nurs Res 12(2):60–68, 1999

12. Bergstrom N, Braden BJ: Predictive validity of the Braden Scaleamong black and white subjects. Nurs Res 51:398–403, 2002

13. Huether SE: Structure, function, and disorders of the integument.In McCance KL, Huether SE (eds): The Biological Basis for Dis-ease in Adults and Children (4th Ed), pp 1434–1468. St. Louis,Mosby, 2002

14. National Cancer Institute: What you need to know about skin can-cer? 2002. Available at http://www.cancer.gov/cancerinfor/wyntk/skin. Accessed July 1, 2003

15. American Cancer Society: Detecting skin cancer. 2003. Available athttp://www.cancer.org. Accessed July 1, 2003

16. Hockenberry MJ, Wilson D, Winkelstein ML, et al. (eds): Wong’sNursing Care of Infants and Children (7th Ed). St. Louis, Mosby, 2003

OTHER SELECTED READINGByers PH, Carta SG, Mayrovitz HN: Pressure ulcer research issues in

surgical patients. Adv Skin Wound Care 13:115, 2000Cuzzell JZ: Wound assessment and evaluation. Dermatol Nurs 13(4):289,

2001Hayes KVD: Skin wellness and illness. In Condon MC (ed): Women’s

Health. Upper Saddle River, NJ, Prentice-Hall, 2004Finch A: Assessment of skin in older people: As the largest organ in the

body, the skin can offer valuable information about the general healthof an older person. Nurs Older People 15(2):29, 2003

Strayer SM, Reynolds P: Diagnosing skin malignancy: Assessment ofpredictive clinical criteria and risk factors. J Fam Pract 53:210, 2003


Chapter 51—Author Queries1. Please cite ref. 4 in the text, in numerical order. It is cited later,

between refs. 13 and 14, but presumably it should be cited firstbetween refs. 3 and 5.

2. Refs. 13 and 14 were switched to preserve numerical order of citation.

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Integumentary Pt Assessment