Chapter 14 : Skin

Melanoma

Basal cell carcinoma (BCC)

Squamous cell carcinoma (SCC)

Melanoma

Squamous cell carcinoma (SCC)

Melanoma

Basal cell carcinoma (BCC)

Squamous cell carcinoma (SCC)

a and b

Squamous cell carcinoma (SCC)

Asians

African Americans

Diagnosing melanoma

Avoid sunburns

Male

Sun exposure

Bowen disease

Every 2-3 hours

Melanoma = Mole risk, susceptible to African Americans, Hispanics, and Asians Actinic keratosis = Rough scaly patch developed from sun exposure Bowen disease = Scaly/thickened patch, precursor to SCC Xeroderma pigmentosum = Severe light sensitivity and skin pigment changes, rare

Sun exposure = Should reapply protection every 2-3 hours Family history and genetic susceptibility = Involves inherited traits and predispositions Fair skin that burns and freckles easily; light hair = Characteristics that make skin more vulnerable to UV radiation Depressed immune system = Reduced ability to fight off diseases

Reduce skin exposure = Limiting the amount of time spent under the sun Always use sunscreen when sun exposure is anticipated = Preventive measure to block harmful UV rays Wear long-sleeve shirts and wide-brimmed hats = Physical barriers to protect the skin from sun exposure Have annual skin cancer screenings = Regular check-ups to detect any potential skin issues early

Male gender = Higher risk of developing skin cancer Human papillomavirus (HPV) = Viral infection that can increase skin cancer risk Alcohol intake; smoking = Lifestyle choices that can increase skin cancer risk Inadequate niacin in diet = Nutritional deficiency that can increase skin cancer risk

Asymmetry = One half of the mole or birthmark does not match the other Border = Edges are irregular, ragged, notched, or blurred Color = Color is not the same all over and may include shades of black, brown, or tan Diameter = Spot is larger than 6 millimeters in diameter (about 1/4 inch – the size of a pencil eraser), although melanomas can sometimes be smaller than this Evolution (changes over time) = Changes in size, shape, color, elevation, or another trait, or a new symptom such as bleeding, itching, or crusting

Melanoma = Benign or dysplastic nevi (mole) Basal cell carcinoma = No specific precursors Squamous cell carcinoma = Actinic (sun) keratoses or SCC in situ

Skin Cancer = Medical therapies using UV or radiation, Smoking, Sun (skin) exposure, Age Pressure Ulcers = Immobility, Incontinence, Lack of sensory perception

Melanoma = Irregular, circular, bordered lesion with hues of tan, black, or blue Basal cell carcinoma = Waxy nodule, pearly borders or red papule, central crater Squamous cell carcinoma = Oozing, bleeding, crusting lesion

Sun protection: Layered clothing, Sunscreen, Avoid sun between 10-4pm = Skin Cancer SCREENING: Complete skin inspection on admission and a minimum of once every 8 to 12 hours thereafter = Pressure Ulcers

Epidermis = Outer layer of skin; undergoes cell division and contains melanin Dermis = Well-vascularized, connective tissue layer containing collagen, elastic fibers, sebaceous glands, sweat glands, and hair follicles Subcutaneous Tissue = Loose connective tissue containing fat cells, blood vessels, and remaining portions of sweat glands and hair follicles Sebaceous Glands = Attached to hair follicles and secrete oily substance that waterproofs the hair and skin

Vellus = Short, pale, fine, and present all over body, also known as peach fuzz Terminal = Longer, darker, coarse hair initiated by puberty, found on scalp, armpits, nasal, eyelashes, ears

Eccrine = Located all over skin and secrete sweat for thermoregulation Apocrine = Small and non-functional until puberty, associated with menstrual cycle, found in armpit, perineal, and areola of breast

Impaired skin integrity = Break in the skin somewhere, defense is lost Hospital-acquired = Invasive medical device or procedure, residing in long-term care facility, presence of MRSA-positive person in facility Community-acquired = Participating in contact sports, sharing personal items, unsanitary or crowded living, working in healthcare industry Immunosuppression = Conditions like cancer, HIV, very young or old age

Poor hygiene or hobby/occupation = Dirty, broken, jagged nails Hypoxia or anemia = Pale cyanotic nails Hypoxia = Clubbing Anemia = Nail spooning

Decreased circulation and with onychomycosis = Thickened nails Infections or trauma = Detachment of plate from bed Respiratory, cardiovascular disease that cause hypoxia = Slow capillary refill Recent illness = Beau’s lines

Cushing disease and polycystic ovary syndrome (PCOS) = Hirsutism (facial hair on females) Adrenal hormones imbalance or steroids side effect = Hirsutism (facial hair on females) Infections = Oiliness/dryness, parasites, and lesions on the scalp Unusual growth = Hair distribution on the body

Stage 1 = Skin intact, red, does not blanch, painful, firm, soft, warmer or cooler than adjacent tissue Stage 2 = Partial thickness, loss of dermis, shallow open ulcer or intact/open/ruptured serum-filled blister Stage 3 = Full thickness skin loss extending into dermis & subQ tissue, slough may be present, undermining or tunneling may be present Stage 4 = Full thickness skin loss with exposed bone, tendon, or muscle, slough or eschar may be present, undermining or tunneling may be present

A = Asymmetry B = Borders that are irregular C = Color variation D = Diameter exceeding 1/4 in or 6 mm E = Evolving/evolution

Maculae = Small, flat, non palpable skin color change, less than 1 cm with a circumscribed border Vesicles = Lesion filled with serous fluid on outer skin layer, visible, looks like blister, less than 0.5 centimeters Wheal = Elevated mass with transient borders and no fluid cavity, caused by movement of serous fluid into the dermis Cyst = Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis

Assess daily = Regular evaluation of skin condition Turn every two hours in bed = Method to prevent prolonged pressure to body Bathe with mild soap or other agent = Hygiene method to prevent skin damage Ambulate if/when possible = Physical activity to maintain blood flow

Poor nutrition and hydration = People need enough fluids, calories, protein, vitamins and minerals in their daily diets to maintain healthy skin and prevent the breakdown of tissues Medical conditions affecting blood flow = Health problems that can affect blood flow, such as diabetes and vascular disease Prolonged pressure to body = Especially bony prominences decreased/absent perception or sensation decreased/absence mobility Increased moisture = Can cause skin breakage and increase risk of infection

Cyanosis = White skin appears blue-tinged; dark skin may appear blue, dull, lifeless lips, nose, cheek, ears Jaundice = Yellow from elevated bilirubin Erythema = Redness Pallor = Slight or pale color

Normal = Scalp is clean and dry; sparse dandruff may be visible; hair is smooth and firm, somewhat elastic, color of scalp- white but not red Abnormal = Patchy gray hair; severe malnutrition in African American children may manifest as copper-red hair color; Excessive scaliness may indicate dermatitis, raised lesions may indicate tumors or infections; dull, dry hair may be seen with hypothyroidism Excessive hair loss = May occur with infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure Patchy hair loss = May result from infections of the scalp, discoid or systemic lupus erythematosus, and some types of chemotherapy

Inspect general skin coloration = Even, no discoloration Palpate skin to assess temperature = Warmth, moisture, texture, tender to touch Palpate to assess mobility and turgor = Skin is mobile with elasticity and returns to original shape quickly Palpate to detect edema = Skin rebounds and does not remain indented

1 = Problem - requires moderate to max assistance; constant friction 2 = Potential problem - moves feebly or requires minimal assistance; during move the skin slides some; maintains good position in chair or bed most of time, but sometimes slides down 3 = None - No apparent problem moves in bed or chair independently and has strength to lift up completely during move; maintains good position in chair or bed at all times

age, fair skin, family hx, male : white 50, moles ,low immune system and chemical exposure

stop smoking , wear sunscreen and protective gear , skin assessments

10 am - 4 pm

melanoma (most serious) , basal cell carcinoma, squamous cell carcinoma (not life-threatening)

squamous cell C

cancer

Perception​

Mobility​

Moisture​

Nutrition​

Friction or shear against surfaces​

Tissue tolerance decreased

Reduces = Inspect the skin at least daily and more often if at greater risk using risk assessment tool (such as Braden Scale or PUSH tool) and keep flow chart to document. Increases = vigorous massage. Reduces = Bathe with mild soap or other agent; limit friction; use warm, not hot, water; set bath schedule that is individualized. Reduces = dry skin: use moisturizers; avoid low humidity and cold air.

Reduces = careful positioning, turning, and transferring techniques to avoid shear and friction or prolonged pressure on any point Reduces = Refer nutritional supplementation needs to primary care provider or dietitian, especially if protein deficient. Reduces = incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products. Increase = sitting in a care for 30 minutes

Macule and patch​

Papule and plaque​

Nodule and tumor​

Vesicle and bulla​

Wheal​

Pustule​

Cyst

Erosion​

Ulcer​

Scar​

Fissure

direct result of disease process

True

Macule = solely color change, flat, < 1 cm (ex: freckles) Patch = color change > 1 cm Papule = something you can feel, < 1 cm (ex: wart) Plaque = flock of papules, > 1 cm (ex: psoriasis)

Nodule = Solid, elevated, hard or soft, > 1 cm Tumor = Few cm, malignant or benign Vesicle = Elevated cavity with serous fluid, "blister" Bulla = Like vesicle but bigger, > 1 cm

Nodule = Fibroma Tumor = Lipoma Vesicle = Herpes simplex, contact dermatitis Bulla = Friction blister, burn

Nodule = > 1 cm Tumor = Few cm Vesicle = Elevated cavity with serous fluid Bulla = > 1 cm

Wheal = Raised, transient, erythematous (ex: mosquito bite) Pustule = Pus in a cavity (ex: acne) Erosion = Scooped out, shallow depression, superficial Ulcer = Deeper depression extending into dermis; irregular shape

Scar = After skin lesion heals, normal tissue is lost and replaced with CT Fissure = Linear crack, extends into dermis Petechia = Tiny hemorrhages; could indicate abnormal clotting Pustule = Pus in a cavity (ex: acne)

Erosion = Scooped out, shallow depression, superficial Scar = After skin lesion heals, normal tissue is lost and replaced with CT Wheal = Raised, transient, erythematous (ex: mosquito bite) Petechia = Tiny hemorrhages; could indicate abnormal clotting

Scar

Fissure

Petechia

Ulcer

Petechia

Fissure

Spider angioma

Telangiectasis

Half-and-half nails

Ecchymosis = Purplish patch resulting from extravasation of blood into skin, > 3 mm Hematoma = Bruise you can feel Cherry angioma = AKA senile angioma, 1-5 mm, smooth, slightly raised bright red dots Spider angioma = Fiery red star shaped marking with solid center; develops on face, neck, or chest

Longitudinal ridging = Some is normal; splinter hemorrhages may be caused by trauma, beau lines occur after acute illness and eventually grow out Half-and-half nails = Nails half white on upper proximal half and pink on distal; may be indicative of chronic renal disease Pitting = Often occurs with psoriasis; pitting and crumbling of nails

Telangiectasis = Caused by vascular dilation; permanently enlarged and dilated vessels visible on skin Spider angioma = Fiery red star shaped marking with solid center; develops on face, neck, or chest; associated with pregnancy, chronic liver disease, may be normal Cherry angioma = AKA senile angioma, 1-5 mm, smooth, slightly raised bright red dots Hematoma = Bruise you can feel

True

True

True

Koilonychia = Spoon-shaped nails that may be seen from trauma to cuticles or nail folds or in iron deficiency anemia, endocrine, or cardiac disease Yellow nail syndrome = Yellow nails grow slow and curved; may be seen in AIDS and respiratory syndromes Paronychia = Red, swollen, tender inflammation of nail folds; acute- usually bacterial, chronic usually fungal Strong odor/foul odor = May indicate disorder of sweat glands

Lesions = May be local or systemic problems Vascular lesions = Bleeding, venous pressure, aging, liver disease, pregnancy Strong odor/foul odor = May indicate disorder of sweat glands Paronychia = Acute- usually bacterial, chronic usually fungal

Spoon-shaped nails = Koilonychia Yellow nails that grow slow and curved = Yellow nail syndrome Red, swollen, tender inflammation of nail folds = Paronychia Strong or foul odor = Disorder of sweat glands

Koilonychia = Spoon-shaped nails that may be seen from trauma to cuticles or nail folds or in iron deficiency anemia, endocrine, or cardiac disease Yellow nail syndrome = Yellow nails grow slow and curved; may be seen in AIDS and respiratory syndromes Paronychia = Red, swollen, tender inflammation of nail folds; acute- usually bacterial, chronic usually fungal Strong odor/foul odor = May indicate disorder of sweat glands

Koilonychia = Iron deficiency anemia, endocrine, or cardiac disease Yellow nail syndrome = AIDS and respiratory syndromes Paronychia = Acute- usually bacterial, chronic usually fungal Strong odor/foul odor = Disorder of sweat glands

Koilonychia = Spoon-shaped nails Yellow nail syndrome = Yellow nails grow slow and curved Paronychia = Red, swollen, tender inflammation of nail folds Strong odor/foul odor = No visual characteristic, detected by smell

Koilonychia = Spoon-shaped nails that may be seen from trauma to cuticles or nail folds or in iron deficiency anemia, endocrine, or cardiac disease Yellow nail syndrome = Yellow nails grow slow and curved; may be seen in AIDS and respiratory syndromes Paronychia = Red, swollen, tender inflammation of nail folds; acute- usually bacterial, chronic usually fungal Strong odor/foul odor = May indicate disorder of sweat glands

Lesions = May be local or systemic problems Vascular lesions = Bleeding, venous pressure, aging, liver disease, pregnancy Yellow nail syndrome = Yellow nails grow slow and curved; may be seen in AIDS and respiratory syndromes Strong odor/foul odor = May indicate disorder of sweat glands

Koilonychia = Trauma to cuticles or nail folds or in iron deficiency anemia, endocrine, or cardiac disease Paronychia = Acute- usually bacterial, chronic usually fungal Vascular lesions = Bleeding, venous pressure, aging, liver disease, pregnancy Strong odor/foul odor = Disorder of sweat glands

Koilonychia

Yellow nail syndrome

Paronychia

Polycystic ovary syndrome (PCOS)

Hypoxia

Anemia

Decreased turgor = dehydration Indentations on skin = edema Copper-red hair color = extreme malnutrition in African American children Dull, dry hair = hypothyroidism

Excessive generalized hair loss = infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure Hirsutism = Cushing or PCOS Slow capillary refill = respiratory, CVD causing hypoxia Nail spooning = anemia

Nail clubbing = hypoxia Slow capillary refill = respiratory, CVD causing hypoxia Nail spooning = anemia Hirsutism = Cushing or PCOS

Decreased turgor = Dehydration Indentations on skin = Edema Copper-red hair color = Extreme malnutrition in African American children Dull, dry hair = Hypothyroidism

Excessive generalized hair loss = Infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure Hirsutism = Cushing or PCOS

Slow capillary refill = Respiratory, CVD causing hypoxia Nail clubbing = Hypoxia Nail spooning = Anemia

Pressure ulcer

19-24 = No risk 15-18 = Mild risk 9 and lower = SEVERE risk 10-12 = High risk

M = moisture A = activity N = nutrition S = sheer or friction & sensory perception

Thinner = Hair Pale, Skin lesions, Dry, Loses turgor = Skin Thickened, yellow, brittle = Nails

Thickened, yellow, brittle = Nail condition Thinner = Hair condition Pale, Skin lesions, Dry, Loses turgor = Skin condition

Thickened, yellow, brittle = Nails Thinner = Hair Pale, Skin lesions, Dry, Loses turgor = Skin