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Physical Assessment - Chapter 2 Integumentary System

Chapter 2: Integumentary System

The skin is the largest organ in the body. The normal adult has over 20 square feet of skin so it is easy to understand how something can go wrong with this much area to cover. As a membranous barrier between a person’s outer and inner surroundings, the skin responds to external changes and also reflects internal changes. An examination of the integument requires some understanding of the structure and function of the system. There also needs to be an awareness of the appearance of the skin, hair, nails, and mucous membranes in healthy and diseased states.

The skin is divided into three layers; the epidermis, the dermis, and the subcutaneous tissues. Epidermal appendages include the hair, nails, sweat glands, and sebaceous glands. These three layers carry out seven major functions which include:

  • Maintaining an internal environment by acting as a barrier to loss of water and electrolytes
  • Protection from external agents that could injure the internal environment
  • Regulation of body heat
  • Acting as a sense organ for touch, temperature, and pain.
  • Self-maintenance and wound repair
  • Production of vitamin D
  • Delayed hypersensitivity reaction to foreign substances

Examination of the head, neck, and breasts will also be included with the discussion of the integumentary system as much of the examination of these areas includes skin assessment.

A careful skin assessment can alert the examiner to cutaneous problems as well as systemic diseases.

Prior to performing a physical assessment of the skin, a health history should be obtained. The following data should be gathered from the patient and/or family members when performing a health history about the integumentary system.

Health History Assessment


Pigmentation changes: Changes in pigmentation may indicate conditions such as vitiligo, Addison’s disease, arsenic toxicity, or uremia. Tinea versicolor, a common fungal infection, causes patches of either hyper- or hypopigmentation on the chest, upper back, and neck. Pigmentation changes in nevi or moles may indicate carcinoma of the skin.

Rashes/Pruritus: The examiner should ask how long the area has been present, whether it itches, and whether it appeared abruptly or seemed to start in a specific area and spread. Patient input as to possible causative factors of any rashes should be ascertained.

Bruising/Bleeding: The patient should be questioned as to any history of unusual bruising or bleeding which could indicate a problem with clotting disorders. Bleeding from moles should be also be noted as this could indicate cancer of the skin.

Nevi/Moles: The patient should be asked if there has been any changes in the size or shape of existing nevi or moles.

Dryness/Sweating: Problems with dry skin or excessive sweating may indicate endocrine disorders such as hypothyroidism. Excessive sweating at night may be indicative of tuberculosis.

Previously Diagnosed Skin Diseases: It is important to assess previously diagnosed skin disorders such as psoriasis or eczema to provide baseline information.

Head, Neck, and Breasts

Hair: Determine any recent color changes (to include the use of dyes or other chemicals), texture, abnormal loss or growth distribution, lesions of scalp, and baldness.

Head: Assess for history of headaches, migraines, trauma, vertigo, dizziness, syncope, lesions, or lumps.

Eyes: Question whether the patient has problems with blurred vision, diplopia, lacrimation, burning, dryness, photophobia, scotomata,visual loss, color blindness, trauma, infections, edema, sties, or cataracts; ask about prosthetic devices and use of eyeglasses and contact lens (include date of last eye exam and results if available).

Ears: Determine if there are problems with decreased hearing, tinnitus, pain, pruritus, discharge, previous infections; note the date and results of last hearing exam if available; assess for use of prosthetic devices.

Nose: Assess for coryza, rhinitis, sinusitis, abnormal or absent sense of smell, obstruction, epistaxis, trauma, and excessive sneezing.

Neck: Collect data about any problems with swelling, enlargement of lymph nodes, goiter, stiffness and limitations of movement, tenderness and any thyroid concerns.

Breasts: Question about trauma, lumps, pain, discharge from nipples, gyne-comastia, and changes in pigmentation; assess self-exam patterns.

Physical Assessment


Physical assessment of the skin begins with a general inspection followed by a detailed examination. When preparing to assess the skin, wear gloves if the patient has any lesions, complains of itching skin, or if the mucous membranes are to be examined.

Color: Note the color of the skin first. Depending upon the person’s race the skin should be flesh-toned appropriate for the person. Jaundice can indicate biliary tract disease or a liver problem; pale yellow skin can indicate a renal problem. A flushed, red face can indicate excessive ETOH intake, fever, localized inflammation, or even embarrassment. Persons who have eaten excessive amounts of yellow or orange vegetables can exhibit pale yellow skin from carotene overload. However, a person with carotene overload will not have yellow colored sclera as is evident in true jaundice.

Temperature Turgor: Use the back of the hand to assess skin temperature for coolness or warmth. When pinched between the thumb and index finger for a few seconds, normally hydrated, taut skin will snap back into place when released. Dehydrated skin or the skin of the elderly patient will form a small tent shape before gradually assuming its normal position.

Moisture: Dry skin can be caused by irritating soap, excessive bathing, or hypothyroidism; dry skin is normally found in elderly people.

Odor: Note any unusual body odor, smell of ETOH, and breath odor.

Scars: Assess for cause, location, appearance (color and size), and degree of tenderness.

Masses: Note location, size, depth, and presence of tenderness.

Fingernails/Toenails: Check for nail bed color, clubbing, and assess capillary refill. Chronic renal problems can cause the lower half of the nail bed to turn white while the top half remains pink.

To assess capillary refill: press down on one of the patient’s nails until it pales. Release the nail and observe for the pink color to return. The normal color should return in less than 3 seconds. Capillary refill can be affected by room and body temperature, vasoconstriction from smoking, or peripheral edema. Finger clubbing, a sign of chronic tissue hypoxia, occurs when the angle between the fingernail and where the nails enters the skin increase. Normal concave nail bases will create a small, diamond-shaped space when the nails of the index fingers of each hand are placed together. Clubbed fingers are convex at the bases and will touch without leaving a space.

Lesions: Lightly palpate any lesions to detect tenderness, firmness, and depth. Measure length, width, and depth also.

Birthmarks/Moles: Note location, color, shape, and size. Assess with the following four warning signs (ABCD) that might indicate the presence of skin cancer:

1. Asymmetrical edges. 2. Skin cancers have irregular borders while non-cancerous growths have smooth, even borders. 3. Refers to color. Note if the nevus has various colored areas instead of being one color. 4. Stands for diameter. Generally, nevi under one-half centimeter in diameter are not cancerous. However, nevi that are larger than this can indicate skin cancer.

Names of Commonly Seen Lesions

Primary lesions are those originally produced by trauma or other stimulation:

macule: A flat, small (1 centimeter or less) lesion with color change. Seen in rubeola, rubella, scarlet fever, roseola infantum.

papule: An elevated, sharply circumscribed, small (1 centimeter), colored lesion. May be pink, tan, red, or any variation. Seen in ringworm and psoriasis.

vesicle or blister: A bulging, small (under 1 centimeter), sharply defined lesion filled with clear, free fluid. Seen as groups in herpes simplex, varicella, poison ivy, and herpes zoster.

bullae: Large (over 1 centimeter) vesicles. Seen on soles and palms in scarlet fever and in sunburn.

pustule: An elevated, sharply circumscribed lesion (less than 1 centimeter) filled with pus.Seen in impetigo, acne, and staphylococcus infections.

wheal: An elevated, white to pink edematous lesion that is unstable and associated with pruritus. Wheals are evanescent – they appear and disappear quickly. Seen in mosquito bites and hives.

petechiae: Tiny, reddish purple, sharply circumscribed spots of hemorrhage in the superficial layers of the skin or epidermis. Petechiae may indicate severe systemic disease such as meningococcemia, bacterial endocarditis, or non-thrombocytopenic purpura and must be reported immediately.

Secondary lesions result from some alteration, usually traumatic, to the primary lesion.

scales: Dried fragments of sloughed dead epidermis. Seen in seborrhea and tinea capitis.

crusts: Dried blood, serum, scales, and pus from corrosive lesions. Seen in infectious dermatitis.

excoriation: Mechanical removal of the epidermis leaving dermis exposed. Scratch or scrape of original lesion.


ulcer: Destruction and loss of epidermis, dermis, and possibly subcutaneous layers.

fissure: A vertical, linear crack through the epidermis and dermis.

scar: Formation of dense connective tissue resulting from destruction of skin.

lichenification: Pronounced thickening of the epidermis and dermis from chronic scratching or rubbing.


Hair: Assess hair for growth distribution, texture, and infestation with lice.

Masses: Use the fingertips to palpate for any masses of the scalp, ears, face, throat, and neck.

Shape: Note if the head is normocephalic in shape or if unusual bulges exist or the head is an odd shape.

Sinuses: Palpate maxillary sinuses (under the cheekbones) and frontal sinuses (just superior to the medial and inner eyebrow area) for sinuses and masses. Transilluminate the sinuses with a penlight to assess whether or not the sinuses are clear. Press the penlight up under the cheekbones and the eyebrows in a darkened room. With normal sinuses, the area will show a faint glow in the area or transilluminate. Sinuses that are filled with mucus or fluid will not transilluminate.


Observe for symmetrical facial features. Assess Cranial Nerves V and VII as instructed in the Neurological System chapter.


Location: The top of the ear should line up with the outer corner of the eye. Low set ears can indicate congenital problems such as kidney disease or Down’s syndrome.

Pinna: Also known as the auricle. Inspect the pinna and palpate for masses or areas of soreness that could indicate an external otitis.

Canal: Exerting a slight upwards and backwards pressure, insert an otoscope slowly into the external ear canal observing for cerumen (color and amount) and redness. Dark skinned people will have black or brown cerumen while light skinned people will have pale to dark orange cerumen. If the canal is occluded with cerumen, do not attempt to remove it with the otoscope as this can be painful. Bulging, red tympanic members can indicated otitis media. Always use clean ear tips for each ear to avoid carrying microorganisms from one side to the other.

Tympanic membrane: Insert the otoscope until the tympanic membrane is visualized. A normal eardrum will appear pearly gray in color with an area of whiteness at the superior edge extending downward. This is the malleus pressing on the membrane. The light reflex (a triangular cone of reflecting light) should be seen in the anterior, inferior portion of the membrane.

Assess Cranial Nerve VIII (Acoustic) as instructed in the Neurological System chapter.


Lids/Eyebrows: Inspect for symmetry and redness. Run fingertips lightly over areas to assess for tenderness or swelling.

Lacrimal sac: Press on the medial, lower orbital rim while looking for abnormal tearing or purulent material being excreted from the inner canthus area.

Position: Assess eye alignment. They should be one-third of the way down the face and about one eyeball’s distance apart.

Sclera: Normal is a white to buff color. Flecks of tan are also normal.

Cornea: Shine a penlight from the sides and straight into the eyes. Note whether the cornea is clear and intact; assess for lesions or discoloration.

Conjunctiva: With gloves on, pull down the lower and upper conjunctiva. The sclera should be clear to pink in color with a shiny appearance. Asians may have yellow sclera. Observe for foreign bodies and color changes.

Pupils: The pupils are normally about one-fourth the size of the iris and are normally round.One in four people (25%) have asymmetrical pupils without the presence of pathology. In a darkened room, shine the light into one eye while the other is closed or covered and observe for constriction. Remove the light source and observe for dilatation. Examine both eyes together with the pen light and observe for symmetrical reactions.

Iris: The irises should be the same color, size, and shape.

Convergence: This is also known as the near reaction. As eyes shift from a far object to a near object, they constrict and move towards the center. Ask the patient to look at a distant point in the room and then look at the examiner’s eyes. Assess for symmetrical movement.

Confrontation: Test the peripheral vision by having the patient cover one eye and look straight ahead with the other. Then hold a finger at the upper edge of his expected visual field and ask him to tell you how many fingers you are holding up. If the patient cannot see your fingers, slowly move it into the expected visual field, noting the point where he can see it. Do this for the lower, left, and right fields for both eyes. Normal peripheral vision is about four feet at twenty inches from the examiner. Intraocular For a rough estimate of intraocular pressure, have the patient close the eyes pressure and press lightly on the eyelid over the eyeball. The resiliency of the eyeball should be equal to your own (assuming yours is normal).

Assess Cranial Nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) as instructed in the Neurological System chapter.


External structure: Examine the external nose for deviation in shape, size, color, and the presence of nasal discharge. Palpate the nose for masses or deviations.

Septum: Tilt the head back and while pushing up the tip slightly, examine the nares for redness, discharge, or foreign bodies.

Obstruction: Press one side of the nare and have the patient breathe in and out while assessing for obstruction.

Drainage: Inspect for presence, amount, color, and consistency.

Mucosa: Inspect for areas of irritation and lesions.


Cervical spine: Have the patient rotate the head and shrug the shoulders against resistance (assessment of Cranial Nerve XI (Spinal Accessory). Limitations of motion can indicate acute or chronic cervical spine problems.

Blood vessels: Palpate the carotid pulses. Using a stethoscope, auscultate the carotids while having the patient hold his breath. Listen for bruits (the sound of turbulent blood flow in the carotids).

Trachea: Palpate the trachea; it should be in the midline without deviation.

Thyroid: The thyroid lies below the larynx in the lower third of the neck. Stand behind the patient and have them tilt the head to the right, displace the thyroid to the left and ask him to swallow. Palpate for masses as the thyroid gland moves up and down. Repeat for the left side.

Lymph nodes: Palpate the pre- and postauricular lymph nodes (anterior and posterior to the ear), occipital, cervical, and submental (under the chin) lymph nodes for tenderness and swelling.


Skin: With the patient sitting up and with arms at the sides, inspect the breast skin for smoothness, dimpling, and color. Observe for edema which can indicate lymphatic obstruction suggesting cancer. The breasts are normally different sizes. If a nipple is inverted, ask the patient when this occurred or if it has always been inverted. Also notice any nipple discharge.

Exam: Ask the patient to lie supine so the breasts can be palpated. Place a small pillow under the shoulder on the side of examination and ask the patient to place the hand behind the head. Place your fingers flat on the breast and palpate the breast in concentric circles from the periphery to the center. Note whether the breast tissue is soft, firm, or hard. Palpate the areola and nipple. Compress the nipple between your thumb and index finger and squeeze gently observing for discharge. Then, with the patient seated, palpate the axillary lymph nodes. Palpate the right axilla with the middle three fingers of one hand while supporting the patient’s arm with your other hand. Repeat for the left side.

Note any masses or areas of tenderness.

Breast cancer usually appears in the upper outer quadrant as a hard, immobile, irregular lump. Nipple discharge may occur, and breast skin may become edematous with enlarged pores, discoloration, and an orange-peel appearance. The skin feels thick, hard, and immobile.

Age Related Changes of the Integumentary System

The older person’s skin is wrinkled and has a loss of resiliency. The skin becomes thinner, drier, less elastic, and more fragile as subcutaneous fat diminishes. The elastin fibers are replaced with collagen fibers, and sebaceous and sweat gland activity decreases. Capillary blood flow also decreases which slows wound healing. Fingernails usually thicken, become ridged and brittle, and grow more slowly.

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