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Chapter 11—Skin, Hair, and
Nails Assessment
Integumentary System
• Includes: skin, hair, nails, sweat glands
• Provides vital information about patient health status
• Offers systemic data regarding
– Thermoregulatory; endocrine; respiratory
– Cardiovascular; gastrointestinal; neurological
– Urinary; immune
• Reflects status
– Hydration; nutrition; emotional
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Structure and Function
• Skin
– Epidermis: outermost layer of skin; has five layers
• Function: first line of defense against pathogens
– Dermis: second layer of skin; has two layers
• Function: supports epidermis
• Contains
• Blood vessels; nerves; sebaceous glands
• Lymphatic vessels; hair follicles; sweat glands
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Structure and Function—(cont.)
• Skin—(cont.)
– Subcutaneous layer: fat, loose connective tissue
• Function: provides insulation; caloric reserve
storage; cushioning
• Contributes to skin mobility
• Hair
– Function
• Protects specific body areas; provides insulation
• Enables sensory communication to the nervous
system; contributes to gender identification
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Structure and Function—(cont.)
• Hair—(cont.)
– Vellus hair
• Fine, short, hypopigmented
• Located throughout body
– Terminal hair
• Darker, coarser
• Located on scalp, brows, and eyelids
• Postpubertal: axillae, perineum, legs
• Postpubertal males: chest, abdomen
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Structure and Function—(cont.)
• Hair—(cont.)
– Composed of keratin
– Produced by hair follicles, deep in the dermis
• Present: all body areas, except palms and soles
– Arrector pili muscles responsively contract
• Stimuli: environmental; nervous
• Also known as goosebumps
– Sebaceous glands
• Secrete sebum to maintain moisture, condition
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Structure and Function—(cont.)
• Nails: epidermal appendage
– Some systemic diseases, infectious processes can
affect nail growth rate, thickness.
• Sweat glands
– Function: thermoregulation
• Eccrine glands: cover most of body; most
numerous in palms, soles
• Open directly onto skin
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Structure and Function—(cont.)
• Sweat glands—(cont.)
– 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.
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Structure and Function Overview—(cont.)
Figure 11.1
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Lifespan Considerations: Older Adults
• Effects of aging on integument
– Thinner skin: loses elastin, collagen, subcutaneous
fat
– Decreased resilience; sagging/wrinkling; increased
visibility; fragile superficial vascular structures
– Decreased melatonin; hair follicle atrophy
–
Nail growth slows
• Nails thin, exhibit increased brittleness
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Cultural Considerations
• Cultural variations
– Becoming familiar with cultural variations facilitates
• Communication; accurate assessment
• Necessary patient education
• African Americans
– Keloid formation; Traction alopecia; pseudofolliculitis;
folliculitis barbae; perineal follicularis
– Increased melasma in pregnancy; Mongolian spots
– Skin is commonly dry  ashy dermatitis.
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Cultural Considerations—(cont.)
• Asian
– Southeast Asian men: less body, facial hair
– Common
• Tattoos, body piercings, other skin adornments
– Rarely found outside Asian populations
• Hori nevus; nevus of Ota
• Henna tattoos: Arabic, Indian females
• Common Arabic lesions: Mongolian spots; café au lait
spots; congenital nevi
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Urgent Assessment
• Prompt evaluation; interventions/repair
– Acute dehydration, cyanosis, or acute lacerations
(impaired skin integrity)
– Not usually emergent
• Suspicious lesions: concern about cancer
• Rash + fever: infectious process?
• Acute trauma, burns
– May require immediate attention
– Large area: urgent; potentially life-threatening
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Subjective Data Collection
• Assessment of risk factors
– General health; personal history
– Medications; risk factors
• Risk assessment and health promotion
– Skin self-assessment
• SSE procedure
• Patient education regarding
• Limiting excessive UV radiation
• Characteristics of normal/problematic moles
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Common Symptoms
• Common integumentary symptoms
– Pruritus (itching)
– Rash
– Single lesion/wound
• Lifespan considerations: older adult
• Cultural considerations
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Question
• 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.
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Answer
• 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.
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Objective Data
• Common and specialty or advanced techniques
– Complete skin assessment: head-to-toe
– More common: affected body area only
– Characteristics: color; texture; moisture; turgor;
temperature
– Assess/describe alterations during focused
assessment.
• Objective data collection
– Equipment needed; preparation
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Comprehensive Skin Assessment
• Inspection
– Reposition bedbound patient to visualize all body
surfaces
• Priority areas: bony prominences; skin folds
– 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)
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Comprehensive Skin Assessment—(cont.)
• Palpation
– Assess
• Temperature
• Turgor
– Hair
• Lifespan considerations: older adults
– Common skin assessment findings
– Increased risk for abnormal: ecchymoses/purpuric
lesions; skin cancer
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Critical Thinking
• Integumentary alterations often reflect status of other
systems.
• Laboratory and diagnostic testing
– Scraping: microscopic examination
– Culture and sensitivity: Identify infective lesions or
exudate.
– Wood light: scalp infections
– Biopsy: diseases which manifest lesion changes
• Color, size, shape
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Diagnostic Reasoning
• Nursing diagnosis, outcomes, and interventions
– Critical thinking: cluster data; identify patterns
– 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.
– Interventions: Improve patient’s status (partial list).
• Assess skin, risk for skin breakdown.
– Evaluate: efficacy of interventions to achieve
outcomes.
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Question
• 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 nurse’s best answer?
A. Twice daily
B. Daily
C. Every 2 to 3 days
D. Weekly
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Answer
• C. Every 2 to 3 days
• Rationale: Elderly patients need to bathe less often,
usually every 2 to 3 days.
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