Chapter 11—Skin, Hair, and Nails Assessment

Chapter 11—Skin, Hair, and Nails Assessment

Chapter 11Skin, Hair, and Nails Assessment Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins Integumentary System Includes: skin, hair, nails, sweat glands Provides vital information about patients health status Offers systemic data regarding o Thermoregulatory; endocrine; respiratory o Cardiovascular; gastrointestinal; neurological o Urinary; immune

Reflects status o Hydration; nutrition; emotional Copyright 2019 Wolters Kluwer All Rights Reserved Structure and Function #1 Skin o Epidermis: outermost layer of skin; has five layers Function: first line of defense against pathogens o Dermis: second layer of skin; has two layers Function: supports epidermis Contains

Blood vessels; nerves; sebaceous glands Lymphatic vessels; hair follicles; sweat glands Copyright 2019 Wolters Kluwer All Rights Reserved Structure and Function #2 Skin(cont.) o Subcutaneous layer: fat, loose connective tissue Function: provides insulation; caloric reserve storage; cushioning Contributes to skin mobility Hair

o Function Protects specific body areas; provides insulation Enables sensory communication to the nervous system; contributes to gender identification Copyright 2019 Wolters Kluwer All Rights Reserved Structure and Function #3 Hair(cont.) o Vellus hair Fine, short, hypopigmented Located throughout body o Terminal hair

Darker, coarser Located on scalp, brows, and eyelids Postpubertal: axillae, perineum, legs Postpubertal males: chest, abdomen Copyright 2019 Wolters Kluwer All Rights Reserved Structure and Function #4 Hair(cont.) o Composed of keratin o Produced by hair follicles, deep in the dermis Present: all body areas, except palms and soles

o Arrector pili muscles responsively contract Stimuli: environmental; nervous Also known as goosebumps o Sebaceous glands Secrete sebum to maintain moisture, condition Copyright 2019 Wolters Kluwer All Rights Reserved Structure and Function #5 Nails: epidermal appendage o Some systemic diseases, infectious processes can affect nail growth rate, thickness.

Sweat glands o Function: thermoregulation Eccrine glands: cover most of body; most numerous in palms, soles Open directly onto skin Copyright 2019 Wolters Kluwer All Rights Reserved Structure and Function #6 Sweat glands(cont.) o Function: thermoregulation(cont.) Apocrine glands: located in axillae, genital

areas Open into hair follicles; activate at puberty Milky sweat + bacterial flora = musky odor Sebaceous glands: located throughout body, except palms, soles Secrete sebum: moisture retention, friction protection Inflammation of glands may result in acne. Copyright 2019 Wolters Kluwer All Rights Reserved Structure and Function Overview #7

Copyright 2019 Wolters Kluwer All Rights Reserved Lifespan Considerations: Older Adults Effects of aging on integument o Thinner skin: loses elastin, collagen, subcutaneous fat o Decreased resilience; sagging/wrinkling; increased visibility; fragile superficial vascular structures; decreased turgor o Decreased melatonin; hair follicle atrophy o

Nail growth slows Nails thin, exhibit increased brittleness Copyright 2019 Wolters Kluwer All Rights Reserved Cultural Considerations #1 Cultural variations o Becoming familiar with cultural variations facilitates: Communication; accurate assessment Necessary patient education African Americans o Keloid formation; traction alopecia; pseudofolliculitis;

folliculitis barbae; perineal follicularis o Increased melasma in pregnancy; Mongolian spots o Skin is commonly dry ashy dermatitis. Copyright 2019 Wolters Kluwer All Rights Reserved Cultural Considerations #2 Asian o Southeast Asian men: less body, facial hair o Common Tattoos, body piercings, other skin adornments o Rarely found outside Asian populations

Hori nevus; nevus of Ota Henna tattoos: Arabic, Indian females Common Arabic lesions: Mongolian spots; caf au lait spots; congenital nevi Cupping, coining, therapeutic burning Copyright 2019 Wolters Kluwer All Rights Reserved Urgent Assessment Prompt evaluation; interventions/repair o Acute dehydration, cyanosis, or acute lacerations (impaired skin integrity) o Not usually emergent

Suspicious lesions: concern about cancer Rash + fever: infectious process? Acute trauma, burns o May require immediate attention o Large area: urgent; potentially life-threatening Copyright 2019 Wolters Kluwer All Rights Reserved Subjective Data Collection Assessment of risk factors o General health; personal history o Medications; risk factors

Risk assessment and health promotion o Skin self-assessment Self skinexamination (SSE) Patient education regarding Limiting excessive UV radiation Characteristics of normal/problematic moles Copyright 2019 Wolters Kluwer All Rights Reserved Common Symptoms Common integumentary symptoms o Pruritus (itching)

o Rash o Single lesion/wound Lifespan considerations: older adult Cultural considerations Copyright 2019 Wolters Kluwer All Rights Reserved Question #1 Is the following statement true or false? An Arabic woman comes to the clinic for the first time. One of the cultural considerations the nurse must take into consideration is that a chaperone must be in the room

when this woman is assessed. Copyright 2019 Wolters Kluwer All Rights Reserved Answer to Question #1 True Rationale: Cultural variations can include a refusal from a patient to remove his or her head covering or a requirement for the patient to have a chaperone present during the examination, particularly if the examiner is not the same sex as the patient.

Copyright 2019 Wolters Kluwer All Rights Reserved Objective Data Common and specialty or advanced techniques o Complete skin assessment: head-to-toe o More common: affected body area only o Characteristics: color; texture; moisture; turgor; temperature o Assess/describe alterations during focused assessment. Objective data collection o Equipment needed; preparation

Copyright 2019 Wolters Kluwer All Rights Reserved Comprehensive Skin Assessment #1 Inspection o Reposition bedbound patient to visualize all body surfaces Priority areas: bony prominences; skin folds o Categorize lesions Primary (arise from normal skin) Maculae; papules; nodules; tumors; polyps; wheals; blisters; cysts; pustules; abscesses

Secondary (follow primary lesions) Scar tissue; crusts (from dried burns) Copyright 2019 Wolters Kluwer All Rights Reserved Comprehensive Skin Assessment #2 Palpation o Assess Temperature Turgor o Hair Lifespan considerations: older adults o Common skin assessment findings

o Increased risk for abnormal: ecchymoses/purpuric lesions; skin cancer Copyright 2019 Wolters Kluwer All Rights Reserved Critical Thinking Integumentary alterations often reflect status of other systems. Laboratory and diagnostic testing o Scraping: microscopic examination o Culture and sensitivity: Identify infective lesions or exudate.

o Wood light: scalp infections o Biopsy: diseases which manifest lesion changes Color, size, shape Copyright 2019 Wolters Kluwer All Rights Reserved Diagnostic Reasoning Nursing diagnosis, outcomes, and interventions o Critical thinking: cluster data; identify patterns o Assessment data: identify outcomes (partial list) Skin, mucous membranes are intact. Patient reports no altered sensation or pain at site.

Patient demonstrates measure to protect, heal skin. o Interventions: Improve patients status (partial list). Assess skin, risk for skin breakdown. o Evaluate: efficacy of interventions to achieve outcomes Copyright 2019 Wolters Kluwer All Rights Reserved Question #2 You are caring for an 82-year-old male patient who has been hospitalized after a fall. A family member asks the nurse how often his or her father should bathe. What is

the nurses best answer? A. Twice daily B. Daily C. Every 2 to 3 days D. Weekly Copyright 2019 Wolters Kluwer All Rights Reserved Answer to Question #2 C. Every 2 to 3 days Rationale: Elderly patients need to bathe less often, usually every 2 to 3 days.

Copyright 2019 Wolters Kluwer All Rights Reserved

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