208 Concept: Tissue integrity: Skin, Hair and Nails Assessment Flashcards
What are the 3 layers of skin?
epidermis, dermis and subcutaneous layer
How frequently is the epidermis replaced?
Every 4 weeks
In hospital settings, what tool is commonly used to more formally determine factors that may put a patient at risk for skin tears or breakdowns?
Braden Scale for Predicting Pressure Sore Risk.
What are the main functions of the skin?
Protection, prevention of penetration, perception, temp. regulation, identification, communication, wound repair, absorption/secretion, production of vitamin D.
How does mobility relate to the concept of skin?
Impaired mobility can compromise the integumentary system. Can lead to pressure sores and impaired tissue integrity. This can be deep or superficial. Involves the mucous membranes.
What else are you assessing as you assess skin?
Consider cultural and developmental changes and expected findings. Remember: we are not just assessing the skin - we are collecting data re: circulation, nutritional status, signs of systemic diseases, ability to self-care, assessing for clues about risk for falls, etc. in addition to the state of the integument itself.
What is the scope of skin health?
Ranges from intact skin tissue to damaged skin tissue (partial thickness to full thickness injury)
What are some of the different elements of objective information assessment related to the skin?
- Objective data collection: complete physical exam and regional examination.
- Normal findings include color consistent with genetic background, freckles, moles, birthmarks.
- Note any excessive color changes (pallor, erythema, cyanosis, jaundice). In darker-skinned individuals look for absence of red tones (pallor), erythema not always visible so palpate for warmth, tautness, cyanosis difficult to see as well so look for clinical signs of cyanosis (changes to LOC, resp distress).
- Temperature changes (hypo/hyper)
- Moisture (diaphoresis, dehydration)
- Texture (firm with even texture)
- Thickness (callus), edema (scale 1+ to 4+)
- Mobility and turgor (skins ease of rising and ability to return to place – elasticity of the skin)
- Vascularity or bruising (angiomas, trauma, normally no venous dilations or varicosities, presence of tattoos.
What does ABCDE stand for relative to nevi?
A: Asymmetry B: Border irregularity C: Colour variations D: Diameter greater than 6mm E: Elevation and evolution - enlargement
What are you assessing relative to hair?
- Color
- texture (fine, thick, straight, curly, kinky, shiny),
- distribution (all over body including eyebrows, lashes, scalp, pubis region, vellus hair all over body)
- lesions
- pest inhabitants.
What are you assessing relative to nails?
- Shape/contour (slight curvature, flat, smooth, rounded, clean). Profile sign about 60 degrees, nail base firm to palpate. Curved nails can be normal but angle at base of nail and nail 160 degrees or less.
- Consistency (smooth, brittle, splitting, uniform thickness, nail bed firmly adhered to base).
- Color (translucent to even pink bed). Dark-skinned people may have brown-black pigmented areas or streaks. Normal to have white hairline markings.
- Capillary refill (less than 2 seconds for normal peripheral circulation). Beau’s lines - furrow or groove that extends down to nail bed - occurs with local trauma, acute illness; dent appears at cuticle and moves forward as nail grows.
What developmental considerations are there for skin, hair and nails for infants?
- -Mongolian spot (don’t confuse with bruises)
- Cafe au lait spots; most patches are normal
- 3 erythematous states are common: beefy red flush for first 24 hours, harlequin colour change in side lying position, erythma toxicum (common rash in first 3-4 days of life “flea bite”
- 2 temporary cyanotic conditions may occur: acrocyanosis: disappears with warming and cutis marmorata: transient mottling in the trunk and extremities in response to cooler room temperatures
- physiological jaundice
- carotenemia (Yellow-orange)
- vernix caseosa - covers skin at birth
- texture: milia: don’t squeeze (resolves within a few weeks)
- “storkbite” - vascular marking
- hair: lanugo at birth
- cradle cap can affect infant scalps
What developmental considerations are there for skin, hair and nails for adolescents?
- increased sebaceous activity can lead to increased oiliness and acne
- This can appear as early as 7-8, peaks at 14-16 in girls and 16-19 in boys
What developmental considerations are there for skin, hair and nails for pregnant women?
- striae “stretch marks”; 2nd trimester; face after delivery but don’t disappear
- linea nigra
- chloasma
- vascular spider
What developmental consideration are there for skin, hair and nails for older adults?
Skin thinner with decrease in strength, moisture, and elasticity, decrease in underlying supportive structures including muscle mass and subcutaneous fat. Diminished perception of pain may limit perceptions of injury. Reduced arterial and venous blood flow. Hair and nail growth slow, decline in sebaceous gland activity results in dry, rough, itchy skin. Thin, fragile texture.
What are some abnormal findings in skin in infants?
Diaper rash Candidiasis Impetigo Excema Measles Rubella Varicella
What age group would the following normal findings be associated with? Senile lentigines (liver spots) Keratoses: seborrheic Skin tags Sebaceous hyperplasia Thin, parchment-like skin Skin “tents” by itself Decreased hair growth; changes in thickness, colour Thickened, brittle, or yellow nails
Older adults
What are some of the abnormal findings associated with older adults?
Pressure ulcers (Stages) Skin lesions Tumour Uticaria (hives) Vesicle
When inspecting and palpating the skin, what objective data are you gathering?
Color Temperature Moisture Texture and thickness Edema Mobility and turgor Vascularity or bruising
When assessing lesions, what objective data are you gathering?
Color Elevation Pattern or shape Size Location and distribution on body Exudate
What objective data are you gathering about the hair?
Color Texture Distribution Lesions Inhabitants
What objective data are you gathering about the nails?
Shape and contour
Consistency
Color
- Capillary refill
What patient education topics exist for skin, hoar and nails?
- Use of sunscreen, exposure to chemicals, client perception of skin, hair, nail quality, and nevi self-assessment, use of tanning beds
What is a 1+ on the edema 4 point scale?
Mild pitting, slight indentation, no perceptible swelling of the leg
What is a 2+ on the edema 4 point scale?
Moderate pitting, indentation subsides rapidly
What is a 3+ on the edema 4 point scale?
Deep pitting, indentation remains for a short time, swelling of leg
What is a 4+ on the edema 4 point scale?
Very deep pitting, indentation lasts a long time, gross swelling and distortion of the leg
What 3 sources is skin colour mainly sourced from?
- mainly brown pigment melanin
- yellow-orange tone of the pigment carotene
- red-purple tones of the vascular bed
What are the three layers of the skin?
- epidermis (main ingredient keratin)
- dermis (mostly collagen)
- subcutaneous layer (mainly adipose tissue)
What is hair made of and what are the two types that humans have?
- Keratin
- Vellus hair and terminal hair
What do sebaceous glands produce?
A protective lipid substance, sebum. Most abundant in scalp, forehead, face and chin.
How many stages are there for pressure injuries (decubitus ulcers)?
4 as well as unstageable pressure injury
Shape and configuration lesion: Also called circular; begins in the centre and spreads to periphery. Example: tinea corporis
Annular lesion
Shape and configuration lesion: Lesions that merge together. Example: urticaria (hives)
Confluent lesions
Shape and configuration lesion: Cluster of lesions. Example: vesicles of contact dermatitis
Grouped lesions
Shape and configuration lesion: Twisted, coiled, spiral, snakelike.
Gyrated lesions
Shape and configuration lesion: Distinct, individual lesions that remain separate. Example: molluscum
Discrete lesions
Shape and configuration lesion: Also called iris; resembles iris of eye. Concentric rings of colour in lesions. Example: erythema multiforme
Target lesion
Shape and configuration lesion: A scratch, streak, line, or stripe
Linear lesions
Shape and configuration lesion: Annular lesions that grow together. Examples: psoriasis.
Polycyclic lesions.
Shape and configuration lesion: Linear arrangement along a nerve route. Example: herpes zoster (shingles)
Zosteriform lesion.
Are the following lesions primary or secondary?
- Macule
- Papule
- Patch
- Plaque
- Nodule
- Wheal
- Tumour
- Urticaria (hives)
- Vesicle
- Cyst
- Bulla
- Pustule
Primary lesions
What is a primary lesion?
The immediate result of a specific causative factor; primary lesions develop on previously unaltered skin.
Are the following lesions primary or secondary?
- Crust
- Scale
- Fissure
- Erosion
- Ulcer
- Excoriation
- Scar
- Atrophic scar
- Lichenification
- Keloid
Secondary lesions
What is a secondary lesion?
Resulting from a change in a primary lesion from the passage of time; an evolutionary change,
Which secondary lesion extends into the dermis: Erosion or ulcer?
Ulcer
What are some age-related risks for tissue integrity?
- diaper rash in infants and toddlers
- uncertain mobilization, affinity for placing objects in mouth, inability to protects selves from environmental dangers (infants and toddlers)
- Communicable skin infections (skin-to-skin in kids)
- With aging, result of sun and environmental damage
- older more prone to skin tears
Individual risk factors of tissue integrity?
- related to underlying health conditions (
- exposure to chemical irritants
- radiation
- excessively hot or cold temperatures
- mechanical damage
- genetics
- skin cancer risk
pressure injury risk
