Download - NRS 103 Skin, Hair, and Nails Chapter 9
NANCY SANDERSON MSN, RN
NRS 103 Skin, Hair, and Nails
Chapter 9
Integumentary System
Skin and accessary structures (nails, hair sweat glands and sebaceous glands) form the integumentary system. The skin is elastic, self generating and covers the entire body.
Primary function is to protect the body from microbial and foreign substance invasion and protect internal body structures from physical trauma.
The skin also helps to retain body fluids and electrolytes, provides sensory input about the environment, regulation to body temperatures, excretion of sweat, lactic acid, urea, expressing emotions, ie: blushing, production of vitamin D, repairs own wounds by cell replacement and could tell us of internal disorders by providing valuable clues.
Skin Layers
Epidermis Outermost layer.
Barrier to external penetration
Dermis Underneath epidermis.
Sensory organ for touch, pressure, & temperature. Contains nerves that innervate glands & blood vessels
Subcutaneous Under dermis. Stores
fat, generates heat, provides temperature regulation
Skin: why all the concern!
May be an early sign warning Jaundice—liver disease Nails—anemia, trauma, hypoxia (per oxygenation) Hives/Rash—allergy Rash—infection; auto-immune disease; insect bites
(viruses/bacteria/parasites); tumor (benign/malignant); etc., etc., etc.
Edema—heart or renal disease Tears, fissures, pressure ulcers—injury; immobility
Health History
Any change in skin, hair, or nails? Increase in hair loss, thinning, or breakage? Nail splitting, thickening, discoloration, or separation
from nail bed? Any rashes, sores, lumps, or itching? Any change in appearance of moles? Any lesions that slow or fail to heal? Assess risk factor for skin cancers
Sun exposure, blistering sunburns in childhood, family history, light skin, presence of atypical moles (dysplastic nevi), >50 common moles, or immunosuppresion
Health History
Skin, hair, or nail complaint specific OLDCART of skin/hair/or nail complaint What did rash /lesion look like when first appeared Pain, pruritus, burning? Previous or family hx of similar complaint?
Resolution? Treatments? Change in skin products, detergents, foods,
medications? What medications taking? Any environmental or occupational hazards? Change in nutrition status? Recent life changes (Losses, psychological/ physical
stress) or travel out of US? Major health problems (severe cardiac, endocrine,
respiratory, liver, hematologic, or other)?
Skin Exam Basics
General inspection of entire body, followed
by detailed regional exam Good source of lighting needed, indirect
natural daylight preferred. Consider using small magnifying glass to
aid in examining lesions Use clear flexible measure to assess size Wear gloves for all skin examination! Protect patient’s modesty while exposing
areas as fully as possible Remove socks to examine feet and
between toes
Inspection & Palpation of Skin
ColorTemperature
MoistureTexture
Vascularity/bruising
EdemaLesions
Color
Establish baseline skin color by observing least pigmented skin surfaces (volar surface of forearm, palms/soles, abdomen, and buttocks)
Vascular flush areas: cheeks, bridge of nose, neck, upper chest, flexor surfaces of extremities, genital areas (vascular disturbance, blushing, inc temp compare with less vascular areas)
Pigment labile areas: face, back of hands, flexors or wrist, axillae, mammary areola, midline of abdomen, and genital area (acanthosis nigracans)
Color
Pigmentation changes Cyanosis Jaundice Pallor ErythemaSkin color consistent with genetic background, in dark skin, color may be ashen-gray in mucous membranes
Cyanosis
A dusky blue color, may be visible in nail beds, lips, earlobes, & oral mucosa
In dark skinned- close inspection of nail beds, lips, palpebral conjunctiva, palms, and soles
JaundiceA yellow or green hueOften first visible in sclera, then
mucous membranes, then skinIn dark skinned- May normally
be slightly yellow. View posterior portion of hard palate for yellowish cast. Yellowish/green color in sclera, palms of hands, and soles of feet,
Pallor & Erythema
Pallor Decreased color/red tone in skin. Skin pale Most evident in face, palpebral conjunctiva,
mouth, and nail beds In dark skinned: Brown skin- yellowish
brown tinge; Black skin- ashen gray. Absence of underlying red tones in skin.
Erythema Intense redness of skin In dark skinned: Difficult to see. Usually
associated with increased temperature so palpation should be used to assess for inflammatory condition
Temperature
Temperature Palpate with dorsal aspect of hand on both sides
of body for comparison of patient’s skin temperature
Normal: Warm depending on environment
Abnormal: Increased: burn, localized infection,
fever Decreased: Circulatory problems,
shock
Moisture & Texture
Moisture Normal: Dry
influenced by environmental/body temp and muscular activity
Abnormal: Too moist vs Too dry (maceration) Dryer in winter (decreased humidity) & with
age May indicate dehydration or thyroid disease
Texture Normal: Smooth, firm, soft. Thickness varies in
different areas Abnormal: Loose, wrinkles, rough, thickened,
thin, oily, flaking, scaling, indurated (hardened)
Signs and Symptoms of Dehydration
Altered mental status Lethargy Light headedness Syncope Decreased skin turgor Dry mucus membranes Orthostatic hypotension Moderate oliguria or anuria Resting hypotension
**Aging- decreased body water from 60-40% because increased body fat and increased lean body mass. Impaired water conservation & sodium imbalance**
Lesions
Lesions Traumatic or pathological changes in previously
normal structures Note:
Color Location Size in cm Discharge (amount, color, odor) Characteristics/Classification Shape and configurationNo lesions noted
Lesions, variations in skin color and nail beds
The text book in chapter 9 has very good tables, pictures and descriptions of each condition, characteristics and abnormalities for various integumentary disorders. Please review and familiarize yourself with the definitions of lesions, nail beds and skin problems.
Cancers
Basal Cell CarcinomaSquamous Cell
CarcinomaMalignant Melanoma
•Irregular Borders•Diameter of a malignant skin lesion is usually greater than 6 mm.•Melanoma is a variety of colors.
Patient Education
Monthly inspect skin & scalp noting moles, blemishes and birthmarks
Contact health care provider if skin lesions begins to bleed, ooze, or feel different
A Asymmetry
B Borders irregular
C Color variations
D Diameter >6mm
E Elevation—from flat to
raised F
Feeling –itching, tingling, or stinging
Patient Education
Prevention Wear wide brimmed hat Apply broad-spectrum sunscreen (UVA & UVB)
with SPF of 15 or greater Avoid tanning under the direct sun at midday (10am-4pm) Do not use indoor sunlamps, tanning beds, or
tanning pills Certain medications such as oral contraceptives,
antibiotics, antiinflammatories, antihypertensives, or immunosuppressives may make more sensitive to the sun
Braden Skin Scale cont.
Scores range from 6-23 Lower score means increased risk of skin
breakdown Most facilities use # 18 as a cut off for skin
precautions Assess every shift Frequent turning Special mattress Good Nutrition
Braden Pressure Ulcer Risk Score
Sensory Perception Completely limited (1),very limited (2), slightly limited (3), no
impairments (4) Moisture
Completely moist (1),very moist (2), occasionally moist (3), rarely moist (4)
Activity Bedfast (1), Chairfast (2), Walks occasionally (3), walks
frequently (4) Mobility
Completely immobile (1),very limited (2), slightly limited (3), no limitations (4)
Nutrition Very poor (1), probably inadequate (2),adequate (3), excellent
(4) Friction & Shear
Problem (1), potential problem (2), no apparent problem (3)
Pressure Ulcers
AKA Bedsore Decubitus ulcer
Definition Localized injury to skin and/or underlying tissue
usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction Pressure leads to collapse of blood vessels in area,
leading to ischemia
Pressure Ulcers
Areas most susceptible: Occipital skull, pinna or
ears, sacrum, ischial tuberosity, tronchanter area of hip, ankles, and heels
Contributing factors: Impaired
mobility/immobility, incontinence, poor nutritional status, altered LOC
Pressure Ulcer Stages
(Suspected) Deep Tissue Injury
Stage IStage IIStage IIIStage IVUnstageable
STAGE ISTAGE IISTAGE IIISTAGE IVSTAGE V
ON PG. 122 & 123 ARE VERY GOOD PICTURES AND DESCRIPTION OF
EACH STAGE OF A PRESSURE ULCER PLEASE REVIEW AND FAMILIARIZE
YOURSELF WITH EACH.
Staging of Pressure Ulcers
Inspection/Palpation - Nail Contour
Angle approx 160 degrees. > 180 is abnormal (Clubbing-sign of hypoxia)
Color Nail translucent, nail bed pink Capillary refill <2seconds
Consistency Smooth, regular, thickness
uniform. Nail adherent to nail bed.
Nail changes in Elderly Grow more slowly, lose luster, with longitudinal ridging.
Inspection/Palpation - Hair
Quantity Hair loss
Male pattern baldness, drugs, radiation, hormone levels, stress
Increased hair growth Hirsutism
Lesions Separate hair and assess for lesions or pest
inhabitants No lesions or lice noted
Hair changes in elderly Grey Axilla & pubic hair decreases due to low
testosterone Women with bristly facial hair due to
unopposed testosterone (low estrogen)
Summary
Early signsKnow your terminology How to best assessPrevention, Prevention, Prevention