Chapter 13: Skin, Hair, and Nails Assessment

Chapter 13: Skin, Hair, and Nails Assessment · The integumentary system includes the skin, hair, nails and sebaceous glands. The skin is the bodies largest organ and serves many important functions to maintain health and assist with temperature such as heat/cold · Changes in the skin may be a sign of underlying disease, such as when a patient has a cardiac condition and the skin appears blue b/c of inadequate oxygen perfusion ↳ integumentary findings provide relevant info about the patients hydration, nutrition, and emotional status Anatomy and Physiology Review · skin helps with protection, fluid retention, electrolyte balance, sensation, thermoregulation, synthesis of vitamin D, and insulation · the epidermis is the outermost skin layer. It is the first line of defense, site of vitamin synthesis, and contains 5 layers that are completely replaced every 4 weeks · the dermis is the second layer. It contains connective tissue, collagen, elastic fibers, blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and a subcutaneous adipose (fat) layer · Hair is made of Keratin and is present everywhere except the palms and soles ↳ vellus vs. terminal hair · Nails are on the toes and fingers, changes in the shape, growth, or colour may indicate a systemic problem (such as cardiac disease, liver cirrhosis, malignancy, and immunodeficiency) · sweat glands: eccrine, apocrine, and sebaceous Urgent Assessment · pressure ulcers are areas of tissue necrosis Assessment of the Integument · Protection and Movement due to the prolonged compression of body · Homeostasis and Regulation - sensory perception tissues between a firm surface and bony - gas exchange - mobility prominences - perfusion - tissue integrity · The Braden scale is used to assess an - fluid and electrolytes - pain individual's risk of developing pressure ulcers - nutrition - immunity · Fever, increased HR, inflammation and pain can - elimination - inflammation indicate sepsis - thermoregulation · skin findings indicating dehydration, cyanosis, - cellular regeneration or impaired skin integrity (acute lacerations) - clotting require prompt evaluation and intervention with fluids, oxygen, skin repair, etc. Health History: Subjective Data · Patients with acute trauma and burns may · Review of systems = integumentary require immediate attention, depending on · Risk Factors + health teaching severity ↳ risk factors vs. protective factors ↳ modifiable vs. non-modifiable · personal history? · medications? · family history? (skin cancer, psoriasis, eczema) · lifestyle, occupational history, personal behaviours? · "Tell me about your concern" · rash · specific lesions · pruritus/itching · cutting · bruising · tattoos/piercings · redness/inflammation/ · hair discharge · nails · History of present illness? → 10 attributes of a sign or symptom (LATERSNAPS) 1. location 2. associated signs and symptoms 3. timing 4. environment or exposure factors 5. relieving factors 6. Severity(quantity 7. nature/quality 8. aggravating factors 9. patient perspective 10. Significance to client Physical Assessment: Skin ① Inspection · colour-assess mucous membranes, conjunctiva + uniformity of skin · hygiene · lesions, rashes, erythema, swelling, discharge, odour ② Palpation · temperature Jaundice · moisture · texture · thickness · turgor Skin Lesions/Rashes · size · shape · colour · texture · exudate (pus) · tenderness · configuration · location and distribution · vascular = check for pulsations and blanching General Survey: Skin, hair, nails · constitutive colour: the natural genetically determined colour of the epidermis uninfluenced by UV rays · "Colour blindness" · Fitzpatrick Skin Types Skin Colour · pallor · cyanosis · jaundice · flushing · erythema · ecchymosis→bruising · petechiae - Lesion Types · Macules (patch) · papules · pustules · plaques · nodules · vesicles · bullae · urticaria · scale · crusts · erosions · ulcers · petechiae Pallor Flushing Erythema Cyanosis Ecchymosis Atrophy · purpura · atrophy · scars · telangiectasis Plaque Urticaria Scale Nodule Crust Telangiectases Erosions Purpura Lesion Configurations · Linear · Annular · Target (bull's eye) · Serpiginous · Reticulated · Zosteriform Lesion Texture · Verrucous (wart like) · Lichenification · Induration · Umbilicated · Xanthomas Lesion Colour · red · orange · yellow · violet (vascular lesions) · shades of blue, silver, grey · black (melanocytic, eschar) ABCDE's of Melanoma · A: Asymmetry · B: Border · C: Colour · D: Diameter · E: Evolution Induration Verrucous Umblicated Xanthomas Lichenification Location and Distribution · single or multiple · particular body parts · random or patterned · symmetric or asymmetric · sun-exposed or protected Skin Turgor Wound Healing Phases: ① Inflammatory phase ② Proliferation phase ③ Remodeling phase Wound Classifications · clean: made under sterile conditions · clean-contaminated: made under sterile conditions, but involves the respiratory, gastrointestinal, genital, or urinary tracts · contaminated: exposed to contents of GI or infected fluids, open and traumatic wounds · infected: exposed to contaminants before surgery with evidence of infection Physical Assessment: Hair & Scalp ① Inspection · quality (dandruff, bugs, knits) · distribution (based on age, gender, genetics) ↳ puberty: onset of public hair and increased hair on legs, face, and chest · pattern of loss (smooth skin vs. Stubble) · colour · texture (any change, dry, course, fine, silky etc. ) · scalp ② Palpation · light palpation · scalp mobile and non-tender Physical Assessment: Nails ① Inspection · colour (pink to light brown) · Shape ② Palpation · capillary refill <3sec → perfusion Clubbing → low oxygen Normal nail^ Spooning Beaus Lines