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)
Assessing color changes in ethnic populations
-inflammation: palpate for edema and warmth
-jaundice: assess the sclera and mucous membranes
-pallor
-bruising
-petechia: assess oral cavity and gums (small red purple dots from capillary bursting)
Objective data-the physical exam (cont)
-assess the skin using inspection and palpation for…
-temperature, using proper technique
-hypothermia
-hyperthermia
-moisture, using proper technique
-diaphoresis
-dehydration (togar)
Objective data-the physical exam (cont 2)
-assess the skin using inspection and palpation for…
-texture: normal skin feels smooth and firm
-thickness: observe for thickened areas
-edema: assess for fluid accumulation in interstitial space; using the proper technique and rating scale (legs, feet, hands, arms)
-mobility and turgor: skin elasticity; using the proper technique
-vascularity or bruising, using proper terminology
Objective data-the physical exam (cont 3)
-assess the skin using inspection and palpation for…
-lesions
-color
-elevation
-pattern or shape
-size
-location and distribution on body
-exudate
Objective data-the physical exam (cont 4)
-assess the hair using inspection and palpation for the following…
-color
-texture
-distribution
-lesions
Objective data-the physical exam (cont 5)
-assess the nails using inspection and palpation for the following…
-shape and contour
-profile sign
-consistency
-color
-capillary refill-depress nail edge to blanch for 5 seconds then release, noting return to color-indicates peripheral circulation
Objective data-the physical exam (cont 6)
-promoting health and self-care
-teach skin self-examination, using the ABCDE rule:
-A=asymmetry
-B=border
-C=color
-D=diameter
-E=elevation and enlargement
norms:
symmetrical
regular
change color?
gotten bigger?
gotten taller?
Abnormal findings common shapes and configurations of lesions
**see slides 48-56
-annular or circular: begins in center and spreads to periphery
confluent
lesions run together
discrete
distint and separate
grouped
cluster of lesions
gyrate
twisted, coiled, or snakelike
target
resembles iris of eyes, concentric rings, bullseye
linear
scratch, streak, line, or stripe
polycyclic
-annular lesions grow together (not circular)
zosteriform
-linear arrangement following a unilateral nerve route (shingles)
Additional skin conditions to think critically about…
-petechiae
-purpura
-hematoma
-ecchymosis
-necrosis/eschar
-patterns
-striae
lesions caused by trauma or abuse
**see slides 58-58-60
-pattern injury
-hematoma
-ecchymosis (bruise)
Visual representations of several skin abnormalities
**see slides 62-73
-macule and patch
-papule and plaque
-nodule
-wheal
-vesicle
-cyst
-pustule
-crust
-scale
-fissure
-excoriation
-keloid (hypertrophic scar)
Abnormal findings common skin lesions
-primary contact dermatitis
-allergic drug reaction
-tinea corporis (ringworm of the body)
-psoriasis
-herpes simplex (cold sores)
-herpes zoster (shingles)
abnormal findings-malignant skin lesions and AIDS
-basal cell carcinoma
-squamous cell carcinoma
-malignant melanoma (can mestaticize)
-kaposi sarcoma (opportunistic)
Abnormal hair conditions
-toxic alopecia
-tinea wapitis (scalp ringworm)
-traction alopecia
-seborrheic dermatitis (cradle cap)
-pediculosis capitis (head lice)
-folliculitis barbae (“razor bumps”)
-hirsutism (excessive hair growth)
-furuncle and abscess
Abnormal conditions of the nails
-scabies
-paronychia
-beau lines
-splinter hemorrhages
-onychomycosis
-late clubbing
-pitting
-habit-tic dystrophy
**see slide 78
Summary checklist: skin, hair, and nails
-inspection of the skin, hair, and nails
-color and pigmentation
-texture and distribution
-shape, contour, and consistency
-palpation of the skin, hair, and nails
-temperature, moisture, texture
-edema, mobility, and turgor
-hygiene, vascularity, or bruising
-note presence of lesions
-color, shape, size, configuration, location, and distribution
-teach self-examination
-health promotion
