copyright © 2013 by mosby, an imprint of elsevier inc. skin, hair, and nails dsn kevin dobi, ms,...

CHAPTER 9

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Skin, Hair, and Nails

DSN Kevin Dobi, MS, APRN

Tissue Integrity

Concept represents structural intactness and physiologic function of tissues and conditions that affect integrity.

Tissues referred to: Skin, hair, and nails. Interrelated concepts:

Perfusion Oxygenation Motion Tactile sensory perception Elimination Nutrition Pain

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 2

Anatomy and Physiology

Integumentary system: Skin and accessory structures Hair Nails Sweat glands Sebaceous glands

Skin considered a body organ, an elastic, self-regenerating cover for entire body Primary functions

Protects the body from invasion. Protects internal body structures from physical

trauma. Helps retain body fluids and electrolytes. Produces vitamin D. Helps regulate body temperature.


Anatomy and Physiology: Layers of Skin

Composed of three functionally related layers: Epidermis Dermis Subcutaneous layer (hypodermis)


Anatomy and Physiology: Epidermis

Thin, outermost layer of skin composed of stratified squamous epithelium: Is avascular.

Stratum germinativum is deepest layer: Lies adjacent to rich supply of blood of dermis. Site of active cell generation. As new cells are produced, they push older

cells toward skin surface where they begin to die and undergo process keratinization, causing cells to become flat, hard, and waterproof.


Anatomy and Physiology: Outermost Aspect Epidermis

Stratum corneum is outermost aspect of epidermis: Composed of 30 layers of dead, flattened,

keratinized cells. Exposed layer serves as protective barrier and

regulates water loss. Dead cells are continuously sloughed off and

replaced by new cells moving from the underlying epidermal layers.

Process takes about 30 days. Contains melanocytes that secrete melanin:

Provides pigment. Shields from ultraviolet radiation.Copyright © 2013 by Mosby, an imprint

of Elsevier Inc. 7

Anatomy and Physiology: Dermis

Dermis made up of highly vascular connective tissue. Thickness varies from 1 mm to 4 mm. Blood vessels dilate and constrict in response

to heat and cold, and to internal stimuli of anxiety or hemorrhage, resulting in regulation of body temperature and blood pressure.

Dermal blood nourishes epidermis. Also contains sensory nerve fibers for touch,

pain, and temperature. Arrangement of connective tissue enables

dermis to stretch and contract with body movement.


Anatomy and Physiology: Subcutaneous Layer

Subcutaneous tissue (hypodermis) is not actually skin tissue, but a support structure for dermis and epidermis. Acts as anchor for upper layers. Composed primarily of loose connective tissue

interspersed with subcutaneous fat. Fatty cells help retain heat and provide

protective cushion, and calories.


Anatomy and Physiology:Appendages

Hair, nails, and glands (eccrine sweat glands, apocrine sweat glands, and sebaceous glands) are considered appendages.

Structures formed at junction of epidermis and dermis.


Anatomy and Physiology: Hair

Hair formed from epidermal cells in the dermis Each hair consists of:

A root A shaft A follicle (the root and it’s covering)

Base of follicle contains: Papilla A capillary loop

Melanocytes provide color.


Anatomy and Physiology: Nails

Nails are epidermal cells converted to hard plates of keratin: Composed of a free edge Nail plate Nail root (site of nail growth)

The white crescent-shaped area at base, the lunula, represents new nail growth. Paronychium is tissue adjacent to nail. Cuticle is epidermal tissue (stratum corneum)

growing on nail plate at nail base. Tissue directly under nail is highly vascular and

provides clues to oxygenation status and blood perfusion. Copyright © 2013 by Mosby, an imprint

of Elsevier Inc. 12

Anatomy and Physiology: Eccrine Sweat Glands

Eccrine sweat glands regulate body temperature by water secretion through skin’s surface.

Most numerous and widespread sweat glands on body.

Distributed almost everywhere throughout skin’s surface: Greatest numbers on palms of hands, soles of

feet, and forehead.


Anatomy and Physiology: Apocrine Sweat Glands

Apocrine sweat glands are much larger and deeper than eccrine glands. Found only in axillae, nipples, areolae,

anogenital area, eyelids, and external ears. Secrete odorless fluid containing protein,

carbohydrates, and other substances in response to emotional stimuli.

Body odor is produced by decomposition of apocrine sweat.


Anatomy and Physiology: Sebaceous Glands

Sebaceous glands secrete lipid-rich substance, sebum, which keeps skin and hair from drying out.

Greatest distribution found on face and scalp; although found in all areas of body except palms and soles

Sebum secretion, stimulated by sex hormone activity, varies throughout lifespan.


Present Health Status

Do you have any chronic illnesses? Do you take any medications?

What do you take, and how often? Have you noticed changes in the way your skin

and hair look or feel? Any changes in sensation of your skin?

What kind of work do you do? To your knowledge, are you exposed to any

chemicals at home or work?


Past Health History and Family History

Have you ever had problems with your skin such as skin disease, infections involving skin or nails, or trauma involving skin?

Has anyone in your family ever had skin-related problems such as skin cancer or autoimmune-related disorders such as systemic lupus erythematosus?


Problem-Based History Pruritus is most commonly reported symptom of

skin disease. Other common problems related to skin:

Rashes Pain/discomfort Lesions Wounds Changes in skin color or texture, hair, or nails

Complete symptom analysis: Onset Location Duration Characteristics


Problem-Based History:Pruritus

When did itching first start? Did it start suddenly or over time? Where did it start? Has it spread?

Does anything make itching worse? Does anything relieve it? What have you done to treat it yourself?

What were the circumstances when you first noticed itching? Taking any medications? Contact with possible allergens such as

animals, foods, drugs, plants? Do you have dry or sensitive skin?


Problem-Based History:Rash

When did rash start? Describe what it looked like initially: flat?

raised? How long has rash been present?

Does it itch or burn? What makes it better? Worse? What have you done to treat it? Have you noticed other associated symptoms

such as joint pains, fatigue, or fever? Do you have any known allergies? Does anyone else in your family have a similar

rash? Have you been exposed to others with a

similar rash?


Problem-Based History: Pain/Discomfort of Skin

Describe pain or discomfort: When did pain start? Where is it located? Does pain stay on skin surface, or go deep

inside? Describe pain or discomfort—sharp, dull, achy,

burning, itching: How bad on a scale of 0 to 10? Is pain constant, or does it come and go?

What triggers pain? What makes it worse? Better? Copyright © 2013 by Mosby, an imprint

of Elsevier Inc. 22

Problem-Based History: Lesions or Changes in Moles

Describe lesion you are concerned about. Where is lesion? When did you first notice it? Do you have any symptoms associated with

lesion such as pain, discomfort, pruritus, or drainage?

Describe changes you have noticed in mole: Color Shape Texture Tenderness Bleeding Itching


Problem-Based History: Change in Skin Color

Has there been any generalized change in your skin color? Yellowish tone? Paleness?

Have there been any localized changes in your skin color? Redness? Discoloration of one or both feet? Areas of bruises or patches?

Vitiligo is loss of pigmentation in skin.


Problem-Based History: Skin Texture

In what way has the texture of your skin changed? Thinning Fragile Excessive dryness

Do you have excessively dry (xerosis) or oily (seborrhea) skin? Seasonal, intermittent, or continuous? What do you do to treat it?


Problem-Based History:Wounds

Where is the wound located? What caused the wound? How long have you had it? Do you have associated symptoms such as

pain or drainage? What have you done to treat the wound? Do you typically have problems with wound

healing?


Problem-Based History: Hair

What changes or problems with your hair are you experiencing? When did you notice the changes? Did the changes occur suddenly?

Can you think of any contributory factors? Have you recently experienced stress? Fever? Other illness? What kinds of hair products were used on your

hair recently? Have you changed diet in the last few months? Have you noticed any changes in distribution of

hair growth on your arms or legs?Copyright © 2013 by Mosby, an imprint

of Elsevier Inc. 27

Problem-Based History: Nails

What kind of problem or changes do you have with your nails? When did you first notice changes?

Have you been exposed to chemicals at home or work?

Are your nails brittle? Notice a pitting pattern to nails?

Have you ever had an infection of the nail or around the nail bed?

Do you chew your nails? Do you have difficulty keeping nails clean?

Do your nails appear dirty?


Examination: Skin - Routine

Routine techniques: Inspect for general color and uniformity of

color. Consistent over body surface except

vascular areas. Whitish pink to olive tones to deep brown. Sun-exposed skin is darker.

Note color, pigmentation, vascularity, bruising, lesions, discolorations, or unusual odors.

Systematically inspect and palpate skin from head and neck to trunk, arms, legs, and back.

Provide adequate lighting so that subtle changes are not missed.


Examination: Skin – Routine (contd.)

Inspect skin for localized variations in color: Intentional: Tattoos, coining patterns. Normal localized variations: Pigmented nevi

(moles), freckles, patches, striae (stretch marks secondary to weight gain or pregnancy).


Examination: Skin Palpation

Palpate skin for texture, temperature, moisture, mobility, turgor, and thickness. Texture: Smooth, soft, intact, even surface,

with calluses on hands, feet, elbows, and knees.

Temperature and moisture: Warm and dry. Mobility and turgor: Should move easily when

lifted, with immediate return after released. Thickness: Varies with age and area.

Palms and soles thickest. Eyelids thinnest. Callus: Thick from friction and pressure.


Examination: Hair

Inspect and palpate scalp and hair for surface characteristics, hair distribution, texture, quantity, and color. Surface characteristics: Smooth without

flaking, scaling, redness, or lesions. Should be shiny and soft. Quantity and distribution: Balding patterns

and hair loss; male patterned.

Inspect facial and body hair for distribution, quantity, and texture.


Examination: Nails

Inspect for nails for shape, contour, color, consistency, thickness, and cleanliness. Edges: Smooth and rounded. Contour: Flat and slightly rounded. Consistency: Note grooves, depressions,

pitting, and ridges. Color: Pink, blanched in light-skinned patients;

yellow or brown with vertical lines in dark-skinned patients.

Thickness: Smooth, uniform.


Age-Related Variations: Infants and Children

Assessment of skin among infants and children follow same general principals as described for adults.

Skin lesions common to infants and children include: Milia Erythema toxicum Diaper rash Rashes associated with allergens


Age-Related Variations: Adolescents

Acne is the most common and worrisome skin lesion common to adolescents because of increases in sebaceous gland activity.

Lesions are not only painful, but may also worry patient because of personal appearance.


Age-Related Variations: Older Adults

Skin and hair undergo significant changes with aging.

Lesions are commonly found on older adults. Although many lesions are considered expected

variations associated with the aging process, incidences of skin cancer increase with age.


Patients with Limited Mobility: Hemiplegia, Paraplegia,

Quadriplegia

Patients with limited mobility are at risk for skin breakdown. Secondary to pressure and body fluid pooling

because of inability to feel pressure or decreased ability to change position to relieve pressure.

Examine patient’s skin, especially over bony prominences, and turn patient so that complete skin assessment may be performed.

Patients who operate wheelchairs are at high risk for developing hand calluses; care should be taken to examine patient’s hands.


Patients with Limited Mobility: Expected and Abnormal Findings

–Skin

Assess all contact and skin pressure points for patients who have limited mobility: When a red area of skin is noted, blanch skin

by applying gentle pressure over red areas. If skin becomes white when pressure applied

and resumes red appearance after pressure relieved, circulation is sufficient and redness will disappear.

If skin does not blanch when pressure applied, a stage I pressure ulcer has developed.


Patients with Limited Mobility: Pressure Ulcers

Pressure ulcers are staged as follows: Stage I = Prolonged redness with unbroken

skin. Stage II = Partial-thickness skin loss appears

as a shallow, open ulcer with pink wound bed. Stage III = Full-thickness skin loss with

damage to subcutaneous tissue (may note serosanguineous drainage).

Stage IV = Full-thickness skin loss with exposed bone, muscle, or tendon – may have some eschar or slough.

Unstagable = Eschar or slough may cover the entire wound bed; thus, it is unstagable.


Common Problems and Conditions: Skin

Hyperkeratosis: Clavus (corn). Dermatitis: Variety of superficial inflammatory

conditions: Atopic: Superficial inflammation. Contact: Inflammatory reaction to irritant or

allergen: Localized erythema. May weep, ooze, or crust.

Seborrheic: Chronic inflammation: Scaly, white, or yellowish skin on scalp,

eyebrows, ears, axillae, chest, or back. Stasis: Inflammation seen mostly on lower legs of

older adults: Areas of scaling, petechiae, and brown

pigmentation.


Common Problems and Conditions: Skin (contd.)

Psoriasis: Usually develops by age 20 years. Slightly raised erythematous plaques with

silvery scales. Mostly on elbows, knees, buttocks, lower

back, and scalp. Pityriasis rosea:

Acute, self-limiting disease of young adults in winter.

Thought to be viral.


Common Problems and Conditions:

Lesions Caused by Viral Infections Lesions caused by viral infection:

Warts – caused by HPV. Herpes simplex – group of 8 DNA viruses.

Outbreaks triggered by sun exposure, stress, fever.

Grouped vesicles with an erythematous base. Very painful and highly contagious Eruptions last about 2 weeks

Herpes varicella – Chickenpox Lesions erupt in crops Painful and highly contagious Infectivity lasts about 6 days after final eruptions

Herpes zoster – Shingles Grouped lesions along sensory nerve line


Common Problems and Conditions: Lesions Caused by Fungal Infections

Lesions caused by fungal infection: Tinea infections:

Tinea corporis – Ringworm. Tinea cruris – “Jock itch.” Tinea capitis – scaling and balding. Tinea pedis – “Athlete's foot.”

Candidiasis: Affect superficial layers of skin and mucous

membranes.


Common Problems and Conditions: Lesions Caused by Bacterial

Infections

Lesions caused by bacterial infection: Cellulitis – acute streptococcal or

staphylococcal infection of the skin and subcutaneous tissue.

Impetigo – highly contagious Group A streptococcal infection. Generally occurs on face, around mouth and

nose. Folliculitis – inflammation of hair follicles. Furuncle (abscess or boil) – staphylococcal

infection.


Common Problems and Conditions: Lesions Caused by Arthropods

Lesions caused by arthropods: Scabies – highly contagious mite Sarcoptes

scabiei. Lyme disease – tick infected with Borrelia

burgdorferi. Spider bites – majority from black widow or

brown recluse spiders.


Common Problems and Conditions: Neoplasia

Basal cell carcinoma – most common: Locally invasive; rarely metastasizes. Nodular pigmented lesions with depressed center

and rolled borders. Squamous cell carcinoma:

Initially appears as a red, scaly patch. Melanoma – most serious:

Malignant proliferation of melanocytes. Irregularly shaped with color variations.

Kaposi’s sarcoma: Develops in connective tissue of

immunosuppressed. Dark blue-purple macules, papules, nodules, and

plaques.Copyright © 2013 by Mosby, an imprint

of Elsevier Inc. 46

Common Problems and Conditions: Lesions Caused by Abuse

Bruise: Discoloration from blood seeping into tissues

resulting from trauma. Bites Burns


Common Problems and Conditions: Hair

Pediculosis (lice): Lice on the body are called Pediculosis

corporis. Pubic lice are called Pediculosis pubis.

Alopecia areata: Chronic inflammatory disease of hair follicles

resulting in hair loss on scalp. Hirsutism:

Increase in growth of facial, body, or pubic hair in women.


Common Problems and Conditions: Nails

Onychomycosis: Fungal infection of nail plate caused by Tinea

unguium. Paronychia:

Acute or chronic infection of cuticle caused by staphylococci and streptococci, although Candida may be causative organism.

Ingrown toenail: Occurs when nail grows through lateral nail

and into skin. Usually involves great toe.


Question 1

As the nurse performs a respiratory assessment, he notes a mole on the patient’s back over the right scapula. What is most important for the nurse to ask the patient?

A. “Do you sleep on your right side?”B. “Does your bra strap rub this mole?”C. “Has this mole changed recently?”D. “Have you applied any creams to this mole?”


Question 2

A pustule is noted over the maxilla of the patient. Which of the following illustrates a pustule?


A.

C.

B.

D.

Question 3

An 82-year-old patient is brought to the emergency department with suspected broken right hip. It is believed that she was lying between the bed and the wall for more than 48 hours before she was found. As the nurse conducts an assessment, the following condition over the lower back or coccyx area is seen. What should the nurse document related to this finding?

A. Ecchymosis over coccyxB. Scaling lesion with exudate over

coccyxC. Stage 2 pressure ulcerD. Stage 4 pressure ulcer


Case Study 1

Silas is a 2-year-old male child who attends day care. He has eight siblings at his home. All of his immunizations are up to date. He has a history of strep throat and RSV. His favorite activity is block stacking. His mother reports that he is generally a happy baby who is starting to become potty trained.


Case Study 1 (contd.)

Subjective data: Complains of painful rash on R calf that is

spreading to lower legs. Mother says the rash has been there for 1 week. Mother admits to trying oatmeal baths to stop the

pain, but says this has not helped. Objective data:

Vital signs: T 96.4; P 71; R 14. Height: 2’0. Weight 40 lb.

R calf has a dime-sized, honey-crusted sore. R calf has become increasingly more irritated over

the past week.



Questions:1. What risk factors does Silas have for

impetigo?2. What measures might have helped prevent

impetigo?3. What should the nurse do in this clinical

situation? Prioritize actions.


Case Study 2

Sidney is a 4-year-old male child, who attends preschool. He has five siblings at his home. All of his immunizations are up to date. He has a history of otitis media and RSV. His favorite activity is sandbox play. He reportedly plays most of the day in the sandboxes at school.



Subjective data: Complains of itching, circular, rash behind his

left ear. Mother says the rash has been there for 4 days. Mother admits to trying Vaseline to stop the

itching, but says this made it worse. Objective data:

Vital signs: T 97.2; P 68; R 16. Height: 4’0. Weight 70 lb.

L ear rash has classic ring-worm shape with scaly appearance that spreads to his hairline. No drainage. The rash is quarter sized.



Questions: 1. What risk factors does Sidney have for Tinea

capitis?2. What measures might have helped prevent

Tinea capitis?3. What should the nurse do in this clinical

situation? Prioritize actions.


The End


copyright © 2013 by mosby, an imprint of elsevier inc. skin, hair, and nails dsn kevin dobi, ms,...

Documents

imprint of elsevier

outermost layer of skin

new cells

dead cells

body organ

body fluids

body movement

fatty cells