Chapter 11— Skin, Hair, and Nails Assessment

1. Chapter 11—Skin, Hair, and Nails Assessment

2. Integumentary System • Includes: skin, hair, nails, sweat glands • Provides vital information about patient health status • Offers systemic data regarding • Thermoregulatory; endocrine; respiratory • Cardiovascular; gastrointestinal; neurological • Urinary; immune • Reflects status • Hydration; nutrition; emotional

3. Structure and Function • Skin • Epidermis: outermost layer of skin; has five layers • Function: first line of defense against pathogens • Dermis: second layer of skin; has two layers • Function: supports epidermis • Contains • Blood vessels; nerves; sebaceous glands • Lymphatic vessels; hair follicles; sweat glands

4. Structure and Function—(cont.) • Skin—(cont.) • Subcutaneous layer: fat, loose connective tissue • Function: provides insulation; caloric reserve storage; cushioning • Contributes to skin mobility • Hair • Function • Protects specific body areas; provides insulation • Enables sensory communication to the nervous system; contributes to gender identification

5. Structure and Function—(cont.) • Hair—(cont.) • Vellus hair • Fine, short, hypopigmented • Located throughout body • Terminal hair • Darker, coarser • Located on scalp, brows, and eyelids • Postpubertal: axillae, perineum, legs • Postpubertal males: chest, abdomen

6. Structure and Function—(cont.) • Hair—(cont.) • Composed of keratin • Produced by hair follicles, deep in the dermis • Present: all body areas, except palms and soles • Arrector pili muscles responsively contract • Stimuli: environmental; nervous • Also known as goosebumps • Sebaceous glands • Secrete sebum to maintain moisture, condition

7. Structure and Function—(cont.) • Nails: epidermal appendage • Some systemic diseases, infectious processes can affect nail growth rate, thickness. • Sweat glands • Function: thermoregulation • Eccrine glands: cover most of body; most numerous in palms, soles • Open directly onto skin

8. Structure and Function—(cont.) • Sweat glands—(cont.) • Function: thermoregulation—(cont.) • Apocrine glands: located in axillae, genital areas • Open into hair follicles; activate at puberty • Milky sweat + bacterial flora = musky odor • Sebaceous glands: located throughout body, except palms, soles • Secrete sebum: moisture retention, friction protection • Inflammation of glands may result in acne.

9. Structure and Function Overview—(cont.) Figure 11.1

10. Lifespan Considerations: Older Adults • Effects of aging on integument • Thinner skin: loses elastin, collagen, subcutaneous fat • Decreased resilience; sagging/wrinkling; increased visibility; fragile superficial vascular structures • Decreased melatonin; hair follicle atrophy • Nail growth slows • Nails thin, exhibit increased brittleness

11. Cultural Considerations • Cultural variations • Becoming familiar with cultural variations facilitates • Communication; accurate assessment • Necessary patient education • African Americans • Keloid formation; Traction alopecia; pseudofolliculitis; folliculitis barbae; perineal follicularis • Increased melasma in pregnancy; Mongolian spots • Skin is commonly dry  ashy dermatitis.

12. Cultural Considerations—(cont.) • Asian • Southeast Asian men: less body, facial hair • Common • Tattoos, body piercings, other skin adornments • Rarely found outside Asian populations • Hori nevus; nevus of Ota • Henna tattoos: Arabic, Indian females • Common Arabic lesions: Mongolian spots; café au lait spots; congenital nevi

13. Urgent Assessment • Prompt evaluation; interventions/repair • Acute dehydration, cyanosis, or acute lacerations (impaired skin integrity) • Not usually emergent • Suspicious lesions: concern about cancer • Rash + fever: infectious process? • Acute trauma, burns • May require immediate attention • Large area: urgent; potentially life-threatening

14. Subjective Data Collection • Assessment of risk factors • General health; personal history • Medications; risk factors • Risk assessment and health promotion • Skin self-assessment • SSE procedure • Patient education regarding • Limiting excessive UV radiation • Characteristics of normal/problematic moles

15. Common Symptoms • Common integumentary symptoms • Pruritus (itching) • Rash • Single lesion/wound • Lifespan considerations: older adult • Cultural considerations

16. Question • Is the following statement true or false? An Arabic woman comes to the clinic for the first time. One of the cultural considerations the nurse must take into consideration is that a chaperone must be in the room when this woman is assessed.

17. Answer • True • Rationale: Cultural variations can include a refusal from a patient to remove his or her head covering or a requirement for the patient to have a chaperone present during the examination, particularly if the examiner is not the same sex as the patient.

18. Objective Data • Common and specialty or advanced techniques • Complete skin assessment: head-to-toe • More common: affected body area only • Characteristics: color; texture; moisture; turgor; temperature • Assess/describe alterations during focused assessment. • Objective data collection • Equipment needed; preparation

19. Comprehensive Skin Assessment • Inspection • Reposition bedbound patient to visualize all body surfaces • Priority areas: bony prominences; skin folds • Categorize lesions • Primary (arise from normal skin) • Maculae; papules; nodules; tumors; polyps; wheals; blisters; cysts; pustules; abscesses • Secondary (follow primary lesions) • Scar tissue; crusts (from dried burns)

20. Comprehensive Skin Assessment—(cont.) • Palpation • Assess • Temperature • Turgor • Hair • Lifespan considerations: older adults • Common skin assessment findings • Increased risk for abnormal: ecchymoses/purpuric lesions; skin cancer

21. Critical Thinking • Integumentary alterations often reflect status of other systems. • Laboratory and diagnostic testing • Scraping: microscopic examination • Culture and sensitivity: Identify infective lesions or exudate. • Wood light: scalp infections • Biopsy: diseases which manifest lesion changes • Color, size, shape

22. Diagnostic Reasoning • Nursing diagnosis, outcomes, and interventions • Critical thinking: cluster data; identify patterns • Assessment data: identify outcomes (partial list) • Skin, mucous membranes are intact. • Patient reports no altered sensation or pain at site. • Patient demonstrates measure to protect, heal skin. • Interventions: Improve patient’s status (partial list). • Assess skin, risk for skin breakdown. • Evaluate: efficacy of interventions to achieve outcomes.

23. Question • You are caring for an 82-year-old male patient who has been hospitalized after a fall. A family member asks the nurse how often his or her father should bathe. What is the nurse’s best answer? A. Twice daily B. Daily C. Every 2 to 3 days D. Weekly

24. Answer • C. Every 2 to 3 days • Rationale: Elderly patients need to bathe less often, usually every 2 to 3 days.