Class 3- Skin, Hair, and Nails Flashcards
Importance of skin assessment
-largest organ
-first line of defense, guards against trauma, pathogens…
-supports nerve tissue and blood vessels
-adapts to environmental influences (helps regulate temp)
-assists with fluid balance
-has sensory function
-absorbs and excretes
Importance of skin assessment
-immune system function
-synthesis of vitamin D
-thermoregulation
-wound repair
Conducting a skin assessment
-ongoing during the physical exam
-part of the general survey (first glance)
-requires critical thinking in relation to each patient situation
-requires diligence and thoroughness
-requires thought about prevention
-requires thought about cultural considerations
-requires thought about age considerations
Structure & function (3 layers)
-epidermis
-dermis
-subcutaneous layer
Epidermis
-stratum germinativum or basal cell layer
-stratum corner or horny cell layer
-derivation of skin color
Dermis
-connective tissue or collagen
-elastic tissue
subcutaneous layer
Epidermal appendages
- hair
- sebaceous glands
- sweat glands
-eccrine glands
-apocrine glands - nails
Aging skin
-drier, flatter skin
-decrease in sebum and sweat production
-decrease elasticity
-decreased number of functioning melanocytes
-decrease elastin, collagen, subcutaneous fat
-changes in temperature regulation
-changes in nails
-hair changes
-increase vascular fragility
-skin lesions more common
-increased risk for damage from pressure due to changes in circulation and decreased ability to form new collagen
How does state of health affect condition of skin/
-very thin
-very obese (skin folds –>yeast)
-fluid loss as a result of processes that reduce fluid volume
-excessive perspiration
-diseases of the skin
-inability to sense temperature, friction
-nutritional deficits
-diabetes (developing yeast; poor wound healing)
-gastrointestinal problems resulting in diarrhea
-bed rest
-casts
-medications
-lifestyle variables
-body piercing
Alteration in skin integrity-factors in pressure injury development
-external pressure that compresses blood vessels
-friction and shear that tear, injure blood vessels
-friction and shear that damages the top layer of skin
-bony prominences and the risk of pressure ulcer development
Alteration in skin integrity-factors in pressure injury development (cont)
-external pressure
-friction and shearing
-immobility
-nutrition and hydration
-moisture
-mental status
-age
Using the Braden scale to assess pressure injury risk
-sensory perception
-moisture
-activity
-mobility
-nutrition
-friction & shear
**review slide 16
pressure injury stages
- intact skin with nonblanchable redness
- partial thickness, loss of dermis, presents as abrasion or blister
- full thickness skin loss, subcutaneous tissue may be visible, presents as a deep crater
- full thickness skin loss, tissue necrosis, or damage to muscle, bone, or supporting structures
RYB wound classification
-classification by color
-the universal classification of wounds by color:
-red, yellow, black (RYB) offers an easy to use practical method of evaluating wounds and determining treatment options
-red=protect
-yellow=cleanse
-black=debride
Y=yellow=cleanse
-yellow color in the wound may indicate the present of exudate drainage or slough
-these wounds are characterized by oozing from the tissue
-drainage can be whitish yellow, cream yellow, yellowish green, or beige
-wounds in this stage need cleaning. nursing interventions: irrigating, using wet to moist dressing, non adherent dressing, topical antimicrobial medication
R=red=protect
-red wounds are in the proliferative stage of healing and reflect the color of normal (healthy) granulation tissue
-wounds in this stage need protection with nursing interventions: gentle cleansing, use of moist dressings, application of a transparent dressing, and changing dressing when necessary
B=black=debride
-black color in the wound indicates the presence of eschar (necrotic tissue) which is usually black but may also be brown, gray, or tan
-wound in this stage requires debridement (removal) before the wound can heal
-wounds in this stage are often cared for by advanced practice nurses
B=black=debride (cont)
-wounds in this stage requires debridement (removal of eschar) before the wound can heal
-eschar may be removed by:
-mechanical debridement-using a scapula or scissors to cut away the dead tissue, by scrubbing the wound or applying a wet to moist or dry dressing
-chemical debridement- using a collagenase enzyme agent or autolytic debridement (a dressing that contains wound moisture to help the body produce enzymes to break down the eschar)
-after debridement the wound is treated as a yellow wound and then as healing progress, as a red wound
Wound and skin lesion documentation
-color
-characteristics of edges and wound bed
-size and shape
-depth/tunnels/raised
-odor
-clock method
-drainage characteristics
-treatment method, patient tolerance, date, time signature
Gathering subjective data-health history questions
-previous history of skin disease (allergies, hives, psoriasis, or exzema)
-change in mole
-change in pigmentation (size or color)
-excessive dryness or moisture
-pruritus
-excessive bruising
-rash or lesion
-medications
-hair loss
-change in nails
-environmental or occupational hazards
-self care behaviors
Gathering the objective data during the physical exam
-gloves
-measuring tape/ruler
-penlight
-good lighting
Gathering the objective data during the physical exam (cont)
-using the skills of…
-inspection, key components of the exam
-requires attention to detail
-requires exposing body areas
-requires lifting, turning, moving, opening, etc
-palpation, key component of the exam
-requires attention to detail
-requires gentle touch and thorough approach
-requires use of proper surface of the hand
Objective data-the physical exam
-assess the skin using inspection for…
-color..identify
-general pigmentation
-widespread color change
-pallor (pale; white)
-erythema (red)
-cyanosis (blue; hypoxia)
-jaundice (yellow; eyes/skin)
