Skin, Hair and Nail Assessment Flashcards
Layers of skin
- Epidermal
- Dermal
- Subcutaneous tissue
- Hair
- Sebaceous glands (work to lubricate, protect, and moisture seal)
- Sweat glands (cool)
- Think about depth of injury of burn
Which layer of skin do 1st degree burns affect?
- Mildest form of skin injury, affecting the epidermis.
- Red/Non-blistered
Which layer’s of skin do 2nd degree burns affect?
- Dermis
- Blisters and some thickening of the skin
- Can destroy nerve endings
What are 3rd degree burns?
Extend through every layer of skin, and are the most severe
-Char, waxy white, brown, leathery
What are some functions of the skin?
- Protection
- Perception- touch, pain, pressure, heat
- Temperature
- Identification of self, self image
- Absorption and excretion
- Production of vitamin D
Subjective Data:
- Previous history of skin disease
- Change in pigment
- Change in size or colour in mole (ABCD)
- Excessive dryness, or moisture (xerosis)
- Pruritus (itching)
- Excessive bruising
- Rash or lesion
- Medication
- Hair loss
- Change in mails
- Environmental or occupational hazards
- Self-care behaviours
Additional History: Infant and Children
- Birthmarks
- Change in colour since birth (cyanosis, jaundice)
- Rashes or sores (related to food changes, related to exposure such as change in soap, detergents, sun, diapers)
- Burns or bruises
- Exposure (disease, toxins, plants, scabies/lice, insects)
- Self-destructive habits (scratching, nail-biting, and self harm
- Anal scratching (parasites)
- Sun protection practices
Additional History: Adolescents
•Hormonal skin changes: acne, blackheads
-Emotional response, nutritional patterns, self-care
Additional History: Aging
- Dry skin
- Bruising
- Breakdown, delays in healing
- Change in moles of new lesions
- Skin pain (shingles/herpes zoster)
- Foot changes (diabetic foot)
- Self-care (toe-nails, moisturizers, UV protection)
Inspection of the hair/scalp:
- Texture
- Distribution of hair
- Note any scalp lesions
- Separate hair and check for infestation
- Alopecia: hair falling out
Inspection and palpation of the nails:
- Shape and colour
- Cleanliness, Condition
- Normal filling in 1-2 seconds
- Profile sign (clubbing)
- Consistency
- Markings
Inspection: Skin
- Observe for skin tone, normally it is consistent with their genetic background
- Observe for lesions, rashes, bruising
- Normal to observe freckles, moles (nevus), and birthmarks (pigmented areas
- Acquired Pigment Loss: Vitiglio
- Freckles and Moles also called Nevus
Widespread Color Change:
- Pallor
- Erythema (fever, carbon monoxide poising, venous stasis)
- Cyanosis (blue)
- Jaundice (yellow)
- Ecchymosis (vascularity and bruising)
- May need to check sclera, buccal mucosa, under tongue in dark skinned individuals
Inspect: Lesions
- Inspect with gloves in exudate present
- Note the colour, elevation, pattern, size, location, and exudate
- Palpate and blanche
- Consider using wood light
ABCDE’s of a lesion
A-Asymmetry not round or oval and the two sides do not appear the same
B-Border irregularity- ragged edges or poorly defined margins
C-Colour variations multi-coloured
D-Diameter
E-Elevation and enlargement
Location
Palpate Skin For:
- Texture- normal skin feels smooth and firm with even surface
- Thickness- epidermis is thin over most of the body
- However it is normal to be thickened (calloused) over palms and soles of feet
- Mobility and turgor of skin
Define Mobility and Turgor:
- Mobility= ease of rising
* Turgor= ability to return to place
What is Edema? how would you grade it?
- Fluid accumulating in the intracellular spaces
- Checked by imprinting thumb firmly aginst ankle malleolus or tibia
- A dent created by your finger indicates “pitting edema
Grading:
1+ =mild pitting- slight indent, no particular swelling of leg
2+= moderate pitting,- indent subsides rapidly
3+= deep pitting- indent remains for short time, leg looks swollen
4+= very deep pitting, indent lasts a long time
Developmental considerations: Infants
- Thin, smooth, elastic, more permeable
- Sweat glands underdeveloped- heat regulation problematic
- Less subcutaneous tissue- less insulation
- Pigment system less efficient – sun protection is an issue
What is vernix?
Thick white film on babies after birth, cottage cheese-like
What are normal neonatal changes?
- Red flush for the first 24 hours
- Harlequin sign: occurs in side-lying position, bottom half of body flushed, top half pale
- Erythema toxicum: common rash in first 3-4 days (flea bit rash, transient in newborns)
- Acrocyanosis: blue lips, hand, fingernails, toenails, first few hours of life, dissaperaing with warming
- Curtis Marmorata: mottling in trucking and extremities in response to cool room
Infant: Normal Changes
- Physiologic jaundice
- Milia
- Storkbites
- Mongolian spot (common in aboriginal and European children, looks like brusing)
Assessing Hydration in infants:
- Assessing capillary refill, skin tugor, fontanels
- Skin tugor tested by pinching fold of abdominal skin and watching return to expected state
- Fontanels should be even with cranium (no depression)
Skin considerations: Children and Adolescents
- Epidermis thickens and toughens
- Skin better lubricated
- More dark pigment
- Increased body hair
- Sweat glands click in during adolescence
- Sebaceous glands increase oil production
- Rashes in children usually associated with contact or infectious disease (poison ivy, soap, chicken pocks, measles)
- Hormonal changes in teens leads to increased sweat glands (body odour) and increased sebaceous gland secretions (acne)
- Adult hair distribution axilla, genitals
Skin Considerations: Pregnancy
- More hormones increase change to in pigment to areola, nipples, vulva, axilla, inner thighs
- More sweat and sebaceous glands: worsened acne, sweating
- Hair retention followed by increased loss of retained hairs post delivery
- Melisma
- Linea nigra
- Striae gravidum (stretch marks)
Skin Considerations: Older Adults
•Loss of elastin, collagen, subcutaneous fat, turgor
•Reduced peripheral blood flow
-Easy to tear, bruise, lose heat
-Slow to heal
-Reduced sweat glands, less oil production
-Risk of heat stroke, dry skin
• Reduced pigmentation
-Risk of sunburns
•Hair follicles atrophy, reduces pigmentation
-Hair loss and greying
•Nail growth slows, flat, brittle
Normal changes: Older Adults
- Senile lentigines (liver spots)
- Keratosis
- Skin tags
- Cherry angimoas
- Tenting (loss of fat layer)
- Purpura (bruising due to loss of fat layer)
Cultural Considerations:
•Biocultural differences in amount of melanin in skin
•Produces colour, provides better UV protection
•Nipples, areola, scrotum and labia are generally darker in African and Asian descent
•Inuit adaptation: minimal sweat glands on trunk, increased sweat glands on face
•Alcohol flush syndrome:
-Redness and flushing
-Heat and red splotches on face
-Faster intoxication with alcohol
-90% aboriginals, 50% Asians
•Copper red hair colour in malnourished Africans
Cultural Considerations CONT’D
•Cultural variations -Practice differs around disrobing, direct touch, and gender •African Canadians -Keloid formation -Mongolian spots -Skin is commonly excessively dry -Ashy dermatitis •Asian Population -Men have less body and facial hair •Darker skin pigments -Lower Vit D levels- supplements recommended
Acute Assessment:
•Most skin issue are non-emergent
•Prompt evaluation and interventions recommended for:
-Bleeding, major burns, dirty lacerations, injury with streaking to the lymphatic’s, pressure sores.
•Acute dehydration
•Cyanosis
•Pallor with diminished or absent pulse
Sun Safety: Children/Adults
- Limit exposure from 11am-4pm
- Cover up (loose, light, tightly woven clothes, ears and eyes, uses sun screen)
- SPF 15+ or higher, reapply every 2 hours
- Winter reflection of snow doubles UVA and UVB
Sun Safety: 0-6 months
- Sunscreen is considered toxic
- Cover up, no direct exposure
- Sun screen filters on car windows
Sun Safety: 6-12 months
Safe to apply sunscreen
Primary Skin Lesions:
- Macule
- Papule
- Nodule
- Wheal
- Vesicle
- Cyst
- Pustule
- Patch
- Plaque
Secondary Skin Lesions:
- Scar
- Keloid (excessive fibrous tissue in scar)
- Crust (dried secreations from primary lesion)
- Scale (rapid turnover of epidermal layer)
- Fissure
- Lichenification (skin lines accentuated due to scratching, chronic irritation resembles tree bark)
- Excoriation
- Erosion
- Ulcer
What is Petechiae?
Small red/purple macules or papules that develop in response to trauma, haematological issues (fragile capillaries, small haemorrhages under the skin, trauma, anticoagulant therapy, liver disease)
What is ecchymosis?
Bruising from damaged capillaries
What is purpura?
Bleeding under the skin due to loss of clotting mechanism (flat reddish blue patched, caused by subcutaneous bleeding, fragility of capillaries, bleeding disorders, senile Purpura)
What is a laceration?
Skin tear (superficial, deep)
What is abrasion?
Friction against skin removes layers exposing the dermis
What is a puncture wound?
Occurs when something punctures the skin
What is avulsion?
Trauma forces skin to separate from underlying structures
What is a hematoma?
Similar to bruising but with elevated skin, trauma causes leakage of blood into skin and subcutaneous tissue
Why should you look for injury patterns?
Could be signs of child abuse (bruising, bites, burns, belt marks)
Other Wound Observations:
- Shape, length, width, depth
- Superficial, deep
- Clean, contaminated, infected
- Partial of full thickness
- Presence of necrotic tissue
- Presence of drainage
Wound Drainage
- Serous (clear)
- Sanguineous (bloody)
- Serosanguinous (mixed)
- Purulent (Pus)
