Skin, Hair, Nails assessment, Hygiene

Question 1

What is ABCDE? Only for lesions

Answer 1

• Asymmetry: Oval, two halves of lesion do not look the same
• Boarder irregularity: notching, scalloping, ragged edges, or poorly defined margins
• Colour variation: areas of brown, tan, black, blue, red, white
• Diameter: greater than 6mm
• Evaluation

Question 2

What to assess for in the skin? Part 1(Inspection)

Answer 2

• inspect the skin first; assess the:
  
  • colour -
    
    • state that pt may have benign pigmentations: ABCDE (Asymmetry, Boarder, Colour, Diameter, Elevation)
      
      • freckles,
      • moles (should be symmetrical, flat or raised, have one colour, does not change suddenly in appearance, have regular borders)
      • birthmarks
    • note for:
      
      • general pigmentation -
        
        • should be consistent with genetic background;
        • wide variety; dark-skinned people normally have areas of lighter pigmentation on the palms, nail beds, and lips
      • widespread colour change -
        
        • check the sublingual and buccal mucosae, palpebral conjunctiva, and sclera
      • pallor -
        
        • check for generalized pallor in the mucous membranes, lips, palpebral conjunctiva, and nail beds
      • erythema -
        
        • might not be able to inspect in dark-skinned pts;
        • palpate for increased warmth, tautness, or tightly pulled surfaces
      • cyanosis -
        
        • pt appears blue due to lack of oxygenated blood;
        • check conjunctivae, oral mucosa, and nail beds
        • pt may also present with signs of respiratory distress or decreased consciousness
      • jaundice
        
        • check sclera first

Question 3

What to assess for in the skin? Part 2(Palpation)

Answer 3

• temperature - skin should be warm, and temp should be equal bilaterally
  
  • use dorsa of hand
  • note for hypo/hyperthermia which should not be present
• moisture - normal perspiration on the face, hands, axilla, and skinfolds
  
  • the patient should normally not be diaphoretic or dehydrated.
  • check for dehydration by looking at mucous membranes; should be smooth and moist
• texture - skin should feel smooth and firm with an even surface
• thickness - mostly uniformly thin throughout the body except the palms and soles
  
  • might have calluses in the soles and palms
• edema - should normally not be present
  
  • imprint thumbs firmly against the ankle malleolus, or tibia. should have no pitting edema
  • edema is graded from +1 to +4
• mobility and turgor - skin should be easily pinched, but should return to place immediately
  
  • pinch a fold of skin under the clavicle; skin should not stand up by itself
• vascularity or bruising - venous dilatations and varicosities should not be present
• note any lesions -
  
  • note the lesion’s colour, elevation, pattern, size, location, and presence of exudate

Question 4

What to asses in the Hair?

Answer 4

inspect and palpate for:

• colour - consistent with pt’s genetic background; might be greying
• texture - normally looks shiny, but hair may lose lustre due to products
• distribution - normal distribution according to pt’s age and sex. abnormal growth of facial hair in women indicates hirsutism
• lesions - scalp should be free of lesions, infestation; dandruff may be present

Question 5

What to asses in the Nails?

Answer 5

• Shape and contour - the angle of the nail base should be less than 160 degrees; smooth and rounded; clean
• consistency - should not be brittle or splitting; uniform thickness and nail base should firm
• color - pink nail bed underneath should be visible
• ## capillary refill - should be less than 2 seconds

Question 6

Steps to teach skin self-examination?

Answer 6

• explain to pt:
  
  • to do this once a month
  • the ABCDE rule to detect warning signals of any suspect lesions
  • to use a well-lit room that has a full-length mirror
  • to report any suspect lesions promptly to HCP
• pt to undress completely and inspect their forearms, palms, between fingers
• pt to flex elbows and inspect forearms using mirror
• pt to stand in front of mirror in anatomical position
  
  • ask them to note of any widespread colour changes, lesions
• pt to stand with side facing mirror; inspect both sides
• pt to stand with back facing mirror
  
  • pt to look behind them and inspect lower half of their body
• pt to use another mirror to inspect the upper half of their body
• pt to use comb and sift through hair for lesions, colour of hair, texture, and distribution (or bald spots)
• pt to sit down and use handheld mirror to inspect soles of feet

Question 7

How do you Female perineal care:

Answer 7

1. Assist patient in assuming a dorsal recumbent position, if not contraindicated. Cover the chest and upper extremities with a towel and the lower extremities with a bath blanket. Expose only the genitalia. (If the patient can wash, covering entire body with a bath blanket may be preferable.) Clean the perineal area. Pay special
   attention to skin folds. If fecal material is present, enclose in a fold of underpad and remove with disposable wipes.
2. Wash labia majora. Wipe from the perineum to the rectum. Repeat on the opposite side, using a different section of the washcloth.
3. Separate the labia with your nondominant hand, exposing the urethral meatus and vaginal orifice. Wash downward from the pubic area toward the rectum in one smooth stroke. Use a separate section of cloth for each stroke. Cleanse thoroughly around the labia minora, clitoris, and vaginal orifice. Dry thoroughly.
4. Assist the patient to a comfortable position. Remove disposable gloves, and
   perform hand hygiene.

Question 8

How do you Male perineal care:

Answer 8

1. Lower the side rails, and assist the patient to a supine position. Note restriction in mobility. Patients at risk for infection of the genitalia, urinary tract, or reproductive tract include uncircumcised males and patients with in-dwelling catheters or fecal or urinary incontinence.
2. Gently raise the penis, and place a bath towel underneath. Gently grasp the shaft of the penis. If the patient is uncircumcised, retract the foreskin. If the patient has an erection, defer perineal care until later.
3. Wash the tip of the penis at the urethral meatus first, using a circular motion. Cleanse from the meatus outward. Rinse and dry gently.
4. Return the foreskin to its natural position.
5. Wash the shaft of the penis with gentle but firm downward strokes. Pay special attention to the underlying surface of the penis. Rinse and dry thoroughly. Gently cleanse the scrotum, making sure to wash underlying skin folds. Rinse and dry thoroughly.
6. Inspect the surface of the external genitalia after cleansing.
7. If the patient has bowel or urinary incontinence, apply a thin layer of skin barrier cream to the buttock, anus, and perineal area.
8. Assist the patient to a comfortable position, and cover with the bath blanket.