Transcript NRS 103 Skin, Hair, and Nails Chapter 9

NRS 103 Skin, Hair, and Nails
Chapter 9
NANCY SANDERSON MSN, RN
Integumentary System
 Skin and accessary structures (nails, hair sweat glands and
sebaceous glands) form the integumentary system. The skin
is elastic, self generating and covers the entire body.
 Primary function is to protect the body from microbial and
foreign substance invasion and protect internal body
structures from physical trauma.
 The skin also helps to retain body fluids and electrolytes,
provides sensory input about the environment, regulation
to body temperatures, excretion of sweat, lactic acid, urea,
expressing emotions, ie: blushing, production of vitamin D,
repairs own wounds by cell replacement and could tell us
of internal disorders by providing valuable clues.
Skin Layers
 Epidermis
 Outermost
layer. Barrier
to external penetration
 Dermis
 Underneath
epidermis.
Sensory organ for touch,
pressure, & temperature.
Contains nerves that
innervate glands & blood
vessels
 Subcutaneous
 Under
dermis. Stores fat,
generates heat, provides
temperature regulation
Skin: why all the concern!
 May be an early sign warning
 Jaundice—liver disease
 Nails—anemia, trauma, hypoxia (per oxygenation)
 Hives/Rash—allergy
 Rash—infection; auto-immune disease; insect bites
(viruses/bacteria/parasites); tumor (benign/malignant); etc.,
etc., etc.
 Edema—heart or renal disease
 Tears, fissures, pressure ulcers—injury; immobility
Health History
 Any change in skin, hair, or nails?
 Increase in hair loss, thinning, or breakage?
 Nail splitting, thickening, discoloration, or separation
from nail bed?
 Any rashes, sores, lumps, or itching?
 Any change in appearance of moles?
 Any lesions that slow or fail to heal?
 Assess risk factor for skin cancers
 Sun exposure, blistering sunburns in childhood, family
history, light skin, presence of atypical moles (dysplastic
nevi), >50 common moles, or immunosuppresion
Health History
Skin, hair, or nail complaint specific
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OLDCART of skin/hair/or nail complaint
What did rash /lesion look like when first appeared
Pain, pruritus, burning?
Previous or family hx of similar complaint? Resolution?
Treatments?
Change in skin products, detergents, foods, medications?
What medications taking?
Any environmental or occupational hazards?
Change in nutrition status?
Recent life changes (Losses, psychological/ physical
stress) or travel out of US?
Major health problems (severe cardiac, endocrine,
respiratory, liver, hematologic, or other)?
Skin Exam Basics
General inspection of entire body, followed
by detailed regional exam
Good source of lighting needed, indirect
natural daylight preferred.
Consider using small magnifying glass to
aid in examining lesions
Use clear flexible measure to assess size
Wear gloves for all skin examination!
Protect patient’s modesty while exposing
areas as fully as possible
Remove socks to examine feet and between
toes
Inspection & Palpation of Skin
 Color
 Temperature
 Moisture
 Texture
 Vascularity/bruisin
g
 Edema
 Lesions
Color
 Establish baseline skin color by observing least
pigmented skin surfaces (volar surface of
forearm, palms/soles, abdomen, and buttocks)
 Vascular flush areas: cheeks, bridge of nose,
neck, upper chest, flexor surfaces of
extremities, genital areas (vascular disturbance,
blushing, inc temp compare with less vascular
areas)
 Pigment labile areas: face, back of hands,
flexors or wrist, axillae, mammary areola,
midline of abdomen, and genital area
(acanthosis nigracans)
Color
 Pigmentation changes
 Cyanosis
 Jaundice
 Pallor
 Erythema
Skin color consistent with
genetic background, in dark skin,
color may be ashen-gray in mucous
membranes
Cyanosis
 A dusky blue color, may be
visible in nail beds, lips,
earlobes, & oral mucosa
 In dark skinned- close
inspection of nail beds, lips,
palpebral conjunctiva,
palms, and soles
Jaundice
 A yellow or green hue
 Often first visible in sclera, then
mucous membranes, then skin
 In dark skinned- May normally be
slightly yellow. View posterior
portion of hard palate for yellowish
cast. Yellowish/green color in sclera,
palms of hands, and soles of feet,
Pallor & Erythema
 Pallor
 Decreased color/red tone in skin. Skin pale
 Most evident in face, palpebral conjunctiva, mouth,
and nail beds
 In dark skinned: Brown skin- yellowish brown
tinge; Black skin- ashen gray. Absence of
underlying red tones in skin.
 Erythema
 Intense redness of skin
 In dark skinned: Difficult to see. Usually associated
with increased temperature so palpation should be
used to assess for inflammatory condition
Temperature
 Temperature

Palpate with dorsal aspect of hand on both sides of body
for comparison of patient’s skin temperature
Normal: Warm

depending
Abnormal:

Increased:
on environment
burn, localized infection, fever
Decreased: Circulatory problems, shock
Moisture &
Texture
 Moisture
 Normal: Dry

influenced by environmental/body temp and muscular activity
Abnormal: Too moist vs Too dry (maceration)
 Dryer in winter (decreased humidity) & with age


May indicate dehydration or thyroid disease
 Texture
 Normal: Smooth, firm, soft. Thickness varies in
different areas
 Abnormal: Loose, wrinkles, rough, thickened, thin,
oily, flaking, scaling, indurated (hardened)
Signs and Symptoms of Dehydration
 Altered mental status
 Lethargy
 Light headedness
 Syncope
 Decreased skin turgor
 Dry mucus membranes
 Orthostatic hypotension
 Moderate oliguria or anuria
 Resting hypotension
**Aging- decreased body water from 60-40% because increased
body fat and increased lean body mass. Impaired water
conservation & sodium imbalance**
Lesions
 Lesions
 Traumatic or pathological changes in previously normal
structures
 Note:
Color
 Location
 Size in cm
 Discharge (amount, color, odor)
 Characteristics/Classification
 Shape and configuration
No lesions noted

Lesions, variations in skin color and nail beds
 The text book in chapter 9 has very good tables,
pictures and descriptions of each condition,
characteristics and abnormalities for various
integumentary disorders. Please review and
familiarize yourself with the definitions of lesions,
nail beds and skin problems.
Cancers
 Basal Cell Carcinoma
 Squamous Cell Carcinoma
 Malignant Melanoma
•Irregular Borders
•Diameter of a malignant skin lesion is
usually greater than 6 mm.
•Melanoma is a variety of colors.
Patient Education
 A

 Monthly inspect skin &
scalp noting moles,
blemishes and birthmarks
 Contact health care
provider if skin lesions
begins to bleed, ooze, or feel
different
Asymmetry
 B

Borders irregular
 C

Color variations
 D

Diameter >6mm
 E

Elevation—from flat to raised
 F

Feeling –itching, tingling, or
stinging
Patient Education
Prevention
 Wear
wide brimmed hat
 Apply broad-spectrum sunscreen (UVA & UVB)
with SPF of 15 or greater
 Avoid tanning under the direct sun at midday
 (10am-4pm)
 Do not use indoor sunlamps, tanning beds, or
tanning pills
 Certain medications such as oral contraceptives,
antibiotics, antiinflammatories, antihypertensives,
or immunosuppressives may make more sensitive
to the sun
Braden Skin Scale cont.
 Scores range from 6-23
 Lower score means increased risk of skin breakdown
 Most facilities use # 18 as a cut off for skin
precautions
 Assess every shift
 Frequent turning
 Special mattress
 Good Nutrition
Braden Pressure Ulcer Risk Score
 Sensory Perception

Completely limited (1),very limited (2), slightly limited (3), no
impairments (4)
 Moisture

Completely moist (1),very moist (2), occasionally moist (3),
rarely moist (4)
 Activity

Bedfast (1), Chairfast (2), Walks occasionally (3), walks
frequently (4)
 Mobility

Completely immobile (1),very limited (2), slightly limited (3), no
limitations (4)
 Nutrition

Very poor (1), probably inadequate (2),adequate (3), excellent (4)
 Friction & Shear

Problem (1), potential problem (2), no apparent problem (3)
Pressure Ulcers
 AKA
 Bedsore
 Decubitus ulcer
 Definition
 Localized injury to skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction

Pressure leads to collapse of blood vessels in area, leading to
ischemia
Pressure Ulcers

Areas most susceptible:
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Occipital skull, pinna or ears,
sacrum, ischial tuberosity,
tronchanter area of hip, ankles,
and heels
Contributing factors:

Impaired mobility/immobility,
incontinence, poor nutritional
status, altered LOC
Pressure Ulcer Stages
 (Suspected) Deep
Tissue Injury
 Stage I
 Stage II
 Stage III
 Stage IV
 Unstageable
Staging of Pressure Ulcers
STAGE I
STAGE II
STAGE III
STAGE IV
STAGE V
ON PG. 122 & 123 ARE VERY GOOD
PICTURES AND DESCRIPTION OF EACH
STAGE OF A PRESSURE ULCER PLEASE
REVIEW AND FAMILIARIZE YOURSELF
WITH EACH.
Inspection/Palpation - Nail
 Contour

Angle approx 160 degrees. > 180 is
abnormal (Clubbing-sign of
hypoxia)
 Color


Nail translucent, nail bed pink
Capillary refill <2seconds
 Consistency

Smooth, regular, thickness uniform.
Nail adherent to nail bed.
 Nail changes in Elderly

Grow more slowly, lose
luster, with longitudinal
ridging.
Inspection/Palpation - Hair
 Quantity
 Hair loss
 Male pattern baldness, drugs, radiation,
hormone levels, stress
 Increased hair growth
 Hirsutism
 Lesions
 Separate hair and assess for lesions or pest
inhabitants
 No lesions or lice noted
 Hair changes in elderly
 Grey
 Axilla & pubic hair decreases due to low
testosterone
 Women with bristly facial hair due to unopposed
testosterone (low estrogen)
Summary
 Early signs
 Know your terminology
 How to best assess
 Prevention, Prevention, Prevention