ASSESSING SKIN, HAIR, & NAILS Flashcards
consists of the skin, hair, structures specialized functions. The sebaceous and nails, which are external that serve a variety of and sweat glands originating within the skin also have many vital functions. Each structure’ s function is described separately.
INTEGUMENTARY SYSTEM
consists of dead keratinized cells,
Outermost layer
- Largest organ of the body.
- Acts as a physical barrier protecting underlying tissues from microorganisms, physical trauma, ultraviolet radiation (UVR), and dehydration.
- Gives a unique appearance to individuals.
- Thicker on the palms of the hands and soles of the feet.
- Contains cells responsible for producing melanin
and keratin.
SKIN
is the only one undergoing cell division.
innermost layer
PLAYS A VITAL ROLE IN:
- Temperature maintenance
- Fluid and electrolyte balance
- Absorption
- Excretion
- Sensation
- Immunity
- Vit. D synthesis
- Composed of proteins and mucopolysaccharides, forming a thick, gelatinous material.
- Serves as a supporting matrix for nerve tissue, blood vessels, sweat and sebum glands, and hair follicles.
- Well-vascularized with the inclusion of collagen, elastic fibers, nerve endings, lymph vessels, and the origin of sebaceous and sweat glands.
DERMIS
- the outermost layer of skin on your body protects your body from harm, keeps your body hydrated,
- produces new skin cells and contains melanin, which determines the color of your skin
EPIDERMIS
EPIDERMIS CONSIST OF FOUR LAYERS
STRATUM CORNEUM
STRATUM LUCIDUM
STRATUM GRANULOSUM
STRATUM BASALE
A. GENERAL SKIN COLOR ASSESMENT
Inspection reveals evenly colored skin tones without unusual or prominent discolorations
NORMAL
- Loose connective tissue that includes fat cells, blood vessels, nerves, and the remaining parts of sweat glands and hair follicles.
- Functions as a storage site for fat, serving as an
energy reserve. - Provides insulation to conserve internal body heat.
- Acts as a cushion, offering protection to bones and
internal organs.
SUBCUTANEOUS TISSUE
A. GENERAL SKIN COLOR ASSESMENT
Pallor
Cyanosis
Jaundice
Erythema
ABNORMAL
(Loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia.
Pallor
- May cause white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas.
- Dark skin may appear blue, dull, and lifeless in the same areas.
Cyanosis
Central cyanosis results from
cardiopulmonary problems
whereas ________________ may be a local problem resulting from vasoconstriction.
peripheral cyanosis
Redness of the skin or mucous caused blood flow) membranes, (increased capillaries. It occurs by hyperemia in superficial with any skin injury, infection, or inflammation.
Erythema
Characterized by yellow ranging from pale to
skin tones, pumpkin, particularly of the sclera, oral mucosa, palms and soles
Jaundice
Is a velvety darkening of the skin in the body folds, creases, especially the neck, groin, and axilla.
Acanthosis Nigricans
The variations are due to different amounts of melanin in certain areas. A generalized loss of pigmentation is seen in _________
albinism
Common variations include suntanned areas,
freckles, or white patches known as ________.
vitiligo
- Very light, “Celtic” type
- Often burns, occasionally tans
type I
- Light, or light-skinned European.
- Usually burns, sometimes tans
TYPE II
- Light intermediate, or dark-skinned European
- Rarely burns, usually tans
TYPE III
- Dark intermediate, also “Mediterranean” or “olive skin
- Rarely burns, often tans
TYPE IV
- Dark or “brown” type
- Naturally brown skin, sometimes darkens
TYPE V
- Very dark, or “black” type
- Naturally black-brown skin
TYPE VI
ASSESSMENT TOOL FOR PRESSURE SORE/ BED SORE
- BRADEN SCALE
- PUSH TOOL
- tool to predict pressure sore risk.
BRADEN SCALE
- to document the degree of skin breakdown to provide a baseline to compare the degree of healing or deterioration over time.
PUSH TOOL
PRESSURE ULCER STAGE
STAGE I
STAGE II
STAGE III
STAGE IV
- Intact skin with nonblanchable redness of a localized area usually over a bony prominence.
STAGE 1
- Partial thickness loss of dermis presenting as a shallow open ulcer with a red- pink wound bed.
STAGE II
Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.
STAGE III
Full-thickness tissue loss with exposed bone, tendon, or muscle.
STAGE IV
▪ Initial alteration in the skin
▪ arise from normal skin due to irritation or disease
PRIMARY
Arises from changes in primary lesions e.g. crusts, keloids, scars
SECONDARY
- Small, flat, nonpalpable skin color change
- less than 1cm
MACULE
- May have an irregular border
- greater than 1cm
PATCH
a small, raised, solid mass on the skin that is typically less than 0.5cm
PAPULE
a larger raised area on the skin that is typically more than 0.5 cm
PLAQUE
a palpable, solid, rounded mass that is typically Larger than a papule (0.5cm o 2cm)
NODULE
a general term for a swelling or abnormal growth of tissue (greater than 1to 2cm)
TUMOR
a larger fluid-filled blister that is more than 0.5 cm
BULLA
a small, fluid-filled blister that is less than 0.5 cm
VESICLES
a small, elevated lesion on the skin filled with pus
PUSTULE
a raised, red, and itchy area on the skin that is often transient.
WHEAL
a closed sac-like structure that can contain fluid, pus, or other material.
CYST
thickening and hardening of the skin, often accompanied by exaggeration of the skin’s natural markings
LICHENIFICATION
superficial wounds or abrasions on the skin’s surface
EXCORIATIONS
involves a decrease in the size, thickness, and functionality of the skin or underlying tissues
ATROPHY
are shallow, superficial defects in the skin that involve the loss of the topmost layers of the skin
EROSIONS
a deeper loss of skin that extends into the dermis or even subcutaneous tissue
ULCERS
also known as a scab, is a dried accumulation of blood, serum, or other fluids that forms over a wound or erosion
CRUST
presents as painful, fluid-filled blisters or sores on or around the mouth (HSV-1) or genital area (HSV-2)
HERPES SIMPLES
characterized by redness, itching, and sometimes maceration (softening of the skin) in areas like the groin, armpits, or beneath the breasts
INTERTIGO
the rash is typically widespread and may form a pattern resembling the branches of a tree.
PITYRIASIS ROSEA
a chronic, inflammatory skin condition that affects areas rich in oil glands, such as the scalp, face, and upper chest
SEBORRHEA
also known as scalp ringworm, is a fungal infection of the scalp and hair follicles.
TINEA CAPITIS
a chronic skin condition that primarily affects the face and is characterized by redness, visible blood vessels, bumps, and sometimes, swelling.
ROSACEA
is the deadliest form of skin cancer. However, when detected early, it can be effectively treated. Look for the following warning signs of melanoma when performing skin exams:
Melanoma
SKIN TEXTURE
- Skin is smooth and even
*Use the palmar surface of your three middle
fingers to palpate skin texture
NORMAL
SKIN TEXTURE
- - rough, flaky, dry SKIN is seen in hypothyroidism. Obese clients often report dry, itchy skin
ABNORMAL
SKIN MOISTURE
- Skin surfaces vary from moist to dry depending on the area assessed. Recent activity or a warm environment may cause increased moisture
- OLDER ADULT CONSIDERATIONS : the older client’ s skin may feel dryer because sebum production decreases with age.
- CLINICAL TIP: using the dorsal surfaces of the hand
NORMAL
SKIN THICKNESS
- Skin is normally thin, but calluses (rough, thick sections of epider mis) are common on areas of the body that are exposed to constant pressure (e.g. the heels)
NORMAL
SKIN THICKNESS
- very thin skin may be seen iN clients with arterial insufficiency or in those on steroid therapy
ABNORMAL
SKIN MOISTURE
- Increased moisture sweating) may occur or diaphoresis (profuse in conditions such as hyperthyroidism. Decreased moisture occurs with dehydration or hypothyroidism.
ABNORMAL
SKIN TEMPERATURE
- Cold skin may accompany shock or hypotension. Cool skin may accompany arterial disease.
- Very warm may indicate a febrile state or hyperthyroidism.
ABNORMAL
SKIN TEMPERATURE
- Skin is normally a warm temperature
- CLINICAL TIP: using the dorsal surfaces OF THE hand
NORMAL
- refers to how easily skin can be pinched.
Mobility
- refers to the skin’ s elasticity and how quickly the skin returns to its original shape after being pinched.
Turgor
SKIN MOBILITY AND TURGOR
- Normally the skin is mobile, with elasticity,
and returns to its original shape quickly.
- Skin should recoil in less than 2 seconds
NORMAL
SKIN MOBILITY AND TURGOR
- Decreased turgor is seen in dehydration.
- Recoil that is more than 2 seconds suggests dehydration.
More than 3 seconds is described as tenting
ABNORMAL
PALPATE TO DETECT EDEMA
- Skin rebounds and does not remain indented when pressure is released.
TIP: Use your thumbs to press down on the skin of the feet, ankles, or pretibial area
NORMAL
PALPATE TO DETECT EDEMA
Indentation on the skin may vary from slight to great and maybe in one area or all over the body.
ABNORMAL
refers to the accumulation of excess fluid in the skin, leading to swelling or puffiness.
SKIN EDEMA
Potentially the most distressing change in hair due to its
cosmetic impact, affecting not only scalp hair but also
body hair
ALOPECIA
Nonscarring
Hormonal changes
Medications
Infectious diseases / Thyroid
Follicles may remain intact and may reverse process
NON- CICATRICAL
Scarring
Burns
Radiation
Traction
Irreversible damage to hair follicles
CICATRICAL
- Composed of hard, keratinized cells and grow from a nail root beneath the cuticle.
- Serve to protect the distal portions of the digits and enhance precise movement, aiding in picking up objects
NAILS
Linked to conditions like renal disease and hypoalbuminemia, covering 20% to 60% of the nail.
LINDSAY’ S NAILS OR HALF-AND- HALF NAILS
Associated with factors such as cigarette smoking, fungal infections, and psoriasis.
YELLOW NAILS
:Caused by trauma, cardiovascular, liver, or renal disease.
WHITE NAILS
Indicative of peripheral disease. disease or hypoxia.
BLUE: (CYANOTIC) NAILS WITH CLUBBING
