Introduction
Integumentary system consists of skin, nails, hair, and scalp. The skin is the largest organ in the body. The normal adult has over 20 square feet of skin. It consists of three layers epidermis, dermis, and. A careful assessment can alert the examiner to the cutaneous problems and even the systemic diseases.
Purposes
- To assess any abnormality in the skin.
- To evaluate the effect of treatment on skin lesions or other parts of the integumentary system.
Preparation of Equipment
| Articles | Purpose |
| Screen | Provide privacy. |
| A clean tray containing: | |
| Torch | Aids in visualization of skin lesions. |
| Measuring tape/scale | To measure the lesions. |
| Clean gloves | To prevent cross infection. |
| Paper and pen | To document the findings. |
Procedure
General Preparation of Patient
- Prepare patient physically and mentally.
- Take consent, serves as legal evidence.
- Maintain privacy.
- Ask patient to empty their bladder and bowel.
- Provide loose clothing to facilitate the examination easily.
- Remove any nail polish, shoes and shocks.
- Maintain comfortable environment with good lighting.
Steps of Assessment
- History collection (Subjective data).
- Physical examination (Objective data).
1.History Collection (Subjective Data)
Collect information about the following.
Past Health History
- Pigmentation changes: vitiligo, Addison’s disease, arsenic toxicity or uremia tinea versicolor; patches of either hypo or hyper pigmentation on chest; upper back and neck (fungal infections); nevi or moles (carcinoma of skin).
- Rashes/pruritus: It may indicate bruises or bleeding (clotting disorders/bleeding from moles indicating carcinoma of skin).
- Moles: Any change in the size and shape of existing moles.
- Dryness/sweating: Endocrine disorders (hypothyroidism, tuberculosis).
- Previous health and family history of skin diseases.
Medical History
- History of allergy related to medication, environmental agents or food. Allergic manifestations include photosensitivity, asthma, hay fever, urticaria, Stevens-Johnsons syndrome.
- Medications: Usage of over-the-counter drugs, steroids, oral contraceptives, antibiotics (tetracycline, sulphonamides), anticoagulants, acetylsalicylic acid (ASA), herbal preparation, and traditional therapies.
- Immunization status (particularly tetanus).
- Recent history of viral or bacterial infection especially methicillin-resistant Staphylococcus Aureus (MRSA). seborrheic dermatitis, contact dermatitis, psoriasis, eczema, asthma, rheumatoid arthritis (RA), thyroid disorders, collagen or vascular disorders, skin cancer, immune compromised conditions, e.g., AIDS.
- Surgeries related to keloid excision, recent microdermabrasion, chemical peel, and botox treatment.
- Personal and social history: Obesity, poor hygiene, hot or humid environment, poor environmental sanitation, use of hot tubs or swimming pools, tattoos and piercing, stress or emotional disturbance, exposure to new substances (soaps, foods, pets, plants), insect bite/sting, and recent travel history and contact with infected persons.
- Related systemic problems: Fevers (cellulitis); peripheral edema (cardiovascular); wheeze, dyspnea (anaphylaxis); abdominal pain and diarrhea (e.g., Crohn’s disease); altered level of consciousness (brain-related infection, e.g., meningococcal sepsis).
- Psychological reaction to skin changes (withdrawal from social activities).
2. Physical Examination (Objective Data)
Physical examination of skin begins with a general inspection followed by detailed examination.
Pre-preparation:
- Wash and don gloves to prevent cross infection.
- Provide privacy, drape the patient, and adequately expose only the region to be examined to preserve dignity and promote cooperation.
Postprocedure:
- Reposition the patient and ensure comfort and safety.
- Dispose PPE and replace the articles and wash hands.
- Document for any abnormal findings.
Different Types of Skin Lesions
| Lesions | Examples | |
| 1. | Primary skin lesions | |
| Macula: A flat, nonpalpable skin lesion measuring ≤1 cm (brown, white, tan, purple, red). Not raised or depressed. | Macula in rubella and measles. | |
| Patch: A flat skin lesion measuring >1 cm in size (brown, white, tan, purple, red). Nonpalpable and larger than a macule. | Patch (vitiligo, melasma, ecchymosis). | |
| Papule: A raised, palpable skin lesion measuring ≤1 cm in diameter. Brown or black papules are often melanocytic lesions; red papules are often vascular lesions. | Nevi warts, lichen planus, insect bites, seborrheic keratoses, molluscum contagiosum angioma, skin cancers. | |
| Plaque: Raised skin lesion measuring >1 cm in diameter. Usually have palpable surface change as lesion arises from the epidermis. May have a flat-topped or rounded appearance. | Psoriasis, granuloma annulare, seborrheic dermatitis, eczema. | |
| Vesicle: A small, fluid containing blister, raised, and are translucent. | Chickenpox, herpes zoster, impetigo, dermatitis herpetiformis. | |
| Bulla: A large, clear fluid containing blister measuring >1 cm in diameter. | Burns, bites, irritant/allergic contact dermatitis, drug reactions, classic autoimmune bullous diseases include pemphigus vulgaris and bullous pemphigoid. | |
| Wheals: Sharply demarcated and elevated lesions with irregular borders, erythematous, and may have central pallor, pruritic, and always disappear within 24 hours. | Medication hypersensitivity, insect stings or bites, autoimmune conditions. Physical stimuli (e.g., temperature, pressure, sunlight). | |
| Nodule: A large, firm elevated lesion which usually extends into the dermis and subcutaneous tissue. The surface may be smooth, keratotic, ulcerated, or fungating. | Neurofibromas, cysts, lipomas. | |
| 2. Secondary skin lesions | ||
| Scales: These are dry of greasy masses of keratin that represent thickened stratum corneum. | Silvery-white scales: Psoriasis. Greasy/waxy, yellowish scales: Seborrheic dermatitis. Dry, diffuse, and fish-like scales on lower legs (ichthyosiform): Ichthyosis vulgaris. Fine scales: Tinea versicolor. Scaling in sheets: Scarlet fever. Follicular scales (such as keratotic plugs): Keratosis pilaris. Gritty (sandpaper-like) scales: Actinic keratosis. | |
| Crust: Dried exudate of body fluids (blood, pus, or sebum) on an area of damaged skin (yellow, yellow-green, red or brown). | Tinea capitis, impetigo, scabs on healing wounds. | |
| Erosion: Discontinuity of the skin exhibiting incomplete loss of the epidermis (well circumscribe, depressed). | Candidiasis, eczematous disease, herpes simplex, tinea pedis. | |
| Excoriation: It is a linear abrasion produced by mechanical means (scratching, rubbing, or picking) that usually involves only the epidermis but can reach the papillary dermis. | Skin abrasions. Scars from repeated skin picking. | |
| Ulcer: A breakdown of the skin exhibiting complete loss of the epidermis and often portions of the dermis and subcutaneous fat. | Bacterial, viral, fungal infections. Chronic venous stasis. Vascular compromise (e.g., decubitus ulcers and peripheral arterial disease). | |
| Fissure: A linear crack in the skin that is usually narrow and extends through the epidermis into the dermis. | Angular cheilitis, eczema (fingertips) and intertrigo. | |
| Atrophy: A loss of tissue that can be epidermal, dermal, or subcutaneous (thin, translucent, and wrinkled skin). | Inflammatory and neoplastic skin diseases such as systemic Iupus erythematosus and cutaneous T-cell lymphoma. | |
| Lichenification: Thickening and hyperpigmentation of the skin resulting from repeated rubbing. | Lichen simplex chronicus, prurigo, atopic dermatitis. | |
| Scar: A collection of new connective tissue that may be hypertrophic or atrophic which implies dermo epidermal damage. | Surgical scar, ulcer scars. | |
| Keloids: Hypertrophied scar tissue secondary to excessive collagen formation during healing; elevated, irregular, red. | Ear piercing or surgical incision. | |
| 3. Special skin lesions | ||
| Telangiectasia: Dilation of capillaries that blanch upon pressure, not elevated, often found on the face, trunk, and around the nail bed. Also known as spider veins. | Dermatomyositis, systemic sclerosis, Ataxia telangiectasia, skin cancers, crest syndrome. | |
| Petechiae: Punctate foci of hemorrhage (seen as small red, purple, or brown spots) measuring < 3 mm in size. | Thrombocytopenia, platelet dysfunction, vasculitis, infections (e.g., meningococcemia, rocky mountain spotted fever). | |
| Purpura or ecchymosis: Extravasation of RBCs from cutaneous vessels in the skin and mucous membranes, palpable and non-blanching with diascopy (red, purple, or blue). | Leukocytoclastic vasculitis (e.g., Henoch-Schönlein purpura and polyarteritis nodosa). | |
| Spider angioma: Grouping of small blood vessels at the skin surface. The pattern sometimes resembles the threads of a spider’s web. They are bright red, flat, and easily blanch when one presses their finger on them. | Liver, diseases, pregnancy, vitamin B deficiency. | |
| Chery angioma: A cherry angioma is a noncancerous (benign) skin growth made up of blood vessels, develops on most areas of body, also known as senile angiomas or Campbell de Morgan spots. | Red moles. | |
Special Considerations
- Infants and young children have more permeable skin, increasing risk for fluid loss and infection.
- Cyanosis, pallor, and jaundice may present differently in darker skin tones look at mucous membranes, conjunctiva, and nail beds.
- Use palpation (e.g., warmth, texture, turgor) to supplement visual inspection.
- Assess bony prominences for early signs of pressure injury, especially in immobile or critically ill patients.
- Use validated tools like the Braden Scale to evaluate risk.
- Document location, size, color, drainage, odor, and surrounding tissue.
- Note signs of infection (erythema, warmth, purulent discharge) or delayed healing.
- Skin changes may reflect underlying conditions:
- Dry, flaky skin → hypothyroidism.
- Bronzing → Addison’s disease.
- Butterfly rash → lupus.
- Be aware of cultural skin markings (e.g., cupping, coining).
- Ask about cosmetic products, tattoos, or piercings that may affect assessment.
- Consider sun exposure, chemical irritants, or allergens in patients with dermatitis or unusual lesions.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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