Health Assessment of Skin, Hair, and Nails - PDF

HEALTH ASSESSMENT OF SKIN, HAIR, AND NAILS By: GPCatablan WHY DO WE DO ASSESSMENT? Nurses assess a patient's skin, hair, and nails as part of a comprehensive head-to-toe assessment. These seemingly simple body parts can reveal a lot about a person's overall health. PER...

HEALTH ASSESSMENT OF SKIN, HAIR, AND NAILS By: GPCatablan WHY DO WE DO ASSESSMENT? Nurses assess a patient's skin, hair, and nails as part of a comprehensive head-to-toe assessment. These seemingly simple body parts can reveal a lot about a person's overall health. PERFORMING PHYSICAL ASSESSMENT OF THE SKIN, HAIR, AND NAILS 1. GATHER EQUIPMENT: (GLOVES, EXAM LIGHT, PENLIGHT, MAGNIFYING GLASS, CENTIMETER RULER, WOOD LAMP IF AVAILABLE.) RATIONALE: TO CONSERVE TIME AND ENERGY: EFFICIENCY SAFETY ORGANIZATION PREPAREDNESS PROFESSIONALISM  Gathering Equipment and Explaining Procedure Step 2: Explain the Procedure 1. Informed Consent: Patients have the right to make informed decisions about their healthcare. Understanding the procedure helps them make an informed choice about whether to proceed  PROCEDURE 3. ASK Putting patients in hospital gowns for certain procedures is a common practice for several reasons CLIENT TO GOWN: A. Hygiene and Infection Control: Hospital gowns are designed to be disposable or easily washable, minimizing the risk of cross- contamination between patients. They also provide a barrier to prevent the spread of germs from the patient's clothing to the medical environment. B. Accessibility: Gowns allow for easy access to the areas of the body that need to be examined or treated. This is essential for procedures involving the chest, abdomen, or back. C. Safety: Gowns can help prevent loose clothing from getting caught in medical equipment or interfering with the procedure. D. Comfort: While not the most comfortable garment, a hospital gown can provide a sense of privacy and modesty during a medical procedure. E. Standardization: Using hospital gowns helps to standardize the process, ensuring that everyone involved in the procedure knows where to find access points and how to handle the patient.  LAYERS OF THE SKIN Epidermis -is the outermost layer of your skin. It's the part you see and touch. responsible for protecting the body from the environment. Dermis- This is the middle layer of skin, providing structural support and containing blood vessels, nerves, hair follicles, and sweat glands. Responsible for giving skin its elasticity and strength. Hypodermis- This is the innermost layer of skin, primarily composed of fat cells. The hypodermis acts as an insulator, protecting the body from temperature changes. It also stores energy and helps hold the skin to underlying structures.  FUNCTION OF THE SKIN ❑ The skin is our body's largest organ and serves many important functions: 1. Protection: The skin acts as a barrier against harmful substances, such as bacteria, viruses, and UV radiation from the sun. 2. Regulation of body temperature: The skin helps regulate body temperature through sweating and blood vessel dilation and constriction. 3. Sensation: The skin contains numerous sensory receptors that allow us to feel touch, pressure, temperature, and pain. 4. Excretion: The skin helps eliminate waste products from the body through sweat. 5. Vitamin D production: When exposed to sunlight, the skin produces vitamin D, which is essential for bone health.  A. SKIN 1. NOTE ANY DISTINCTIVE COLOR Assessing skin color is a crucial component of a comprehensive health assessment. Variations in skin color can indicate a wide range of conditions, from benign variations in pigmentation to serious underlying illnesses. Nurses must be adept at observing, documenting, and interpreting these variations.  SKIN 2. I N S P EC T F O R G E N E R A L I Z E D CO LO R VA R I AT I O N S ( B ROW N ES S , Y E L LOW, R E D N ES S , PA L LO R , C YA N O S I S , JAU N D I C E , E RY T H E M A , V I T I L I G O ).  SKIN Maybe assessed at one time or as each aspect of the body is assessed Utilizes inspection, palpation (sometimes olfaction) Olfaction assessment may include: -pungent body odor: related to poor hygiene -hyperhidrosis: excessive perspiration -bromhidrosis: foul-smelling perspiration Check for: A. PALLOR- Inadequate circulating blood and or hemoglobin  SKIN CHECK FOR: B. CYANOSIS : bluish-tinged; result of reduction in tissue oxygenation; nail beds, lips and buccal mucosa  INSPECT THE SKIN FOR “BROWNESS” POSSIBLE SKIN PROBLEM: 1. MELASMA: This common pigmentation disorder causes darker patches on the skin, primarily on the face. It's often triggered by hormonal changes, such as those during pregnancy or while taking birth control pills, and sun exposure. Melasma patches are typically brown or gray in color  SKIN CHECK FOR: D. Erythema: Skin redness (maybe associated with Rashes or other skin conditions)  SKIN CHECK FOR: E. Hyperpigmentation: -confined in an area birthmark Hypopigmentation  SKIN CHECK FOR: F. Hypopigmentation: vitiligo (patches of hypopigmented skin; albinism SKIN VITILIGO Vitiligo is a long-term skin condition that causes patches of the skin to lose their color. This happens when melanocytes, the cells that produce melanin (the pigment that gives skin its color), are destroyed or stop working. SKIN SKIN LESIONS: 3. INSPECT FOR SKIN BREAKDOWN 4. INSPECT FOR PRIMARY, SECONDARY, OR VASCULAR LESIONS. NOTE THE SIZE, SHAPE, LOCATION, DISTRIBUTION, AND CONFIGURATION), USE WOOD LAMP IF FUNGUS IS SUSPECTED.  SKIN ❖PRIMARY Those that appeared initially in response to some change in external or internal environment of the skin: -macule patch, Papule, Plaque, nodule tumor, Papular drug eruption, Psoriasis, Cyst, Wheal MACULE PATCH FLAT UNELEVATED CHANGE IN COLOR. MACULES ARE 1MM TO 1 CM (0.04TO 0.4 IN.) IN SIZE AND CIRCUMSCRIBED. EXAMPLES; FRECKLES, MEASLES, PETECHIAE, FLAT MOLES. PATCHES ARE LARGER THAN 1CM (0.4). AND MAY HAVE AN IRREGULAR SHAPE. EXAMPLE, PORT WINE BIRTHMARK, VITILIGO (WHITE PATCHES), RUBELLA. PAPULE Circumscribed, solid elevation of skin. Papules are less than 1 cm (0.4 in). Examples: warts, acne, pimples, elevated moles.  PAPULAR DRUG ERUPTION Vesicle or bulla filled with pus. Example: acne vulgaris, impetigo Vesicle- A small, fluid-filled blister, typically less than 5 mm in diameter. Think of a tiny bubble on the skin. Acne vulgaris- “acne” PLAQUE Plaques are larger than 1cm (0.4 in). Examples: Psoriasis, rubeola  NODULE, TUMOR Elevated, solid, hard mass that extends deeper into the dermis than a papule. Nodules have a circumscribed border and are 0.5 to 2 cm (0.2 to 0.8 in.). Examples: Squamous cell carcinoma, fibroma. Tumors are larger 2 cm (0.8in.) and may have an irregular border. Examples: Malignant melanoma, hemangioma  VESICLE BULLA A circumscribed, round or oval, thin translucent mass filled with serous fluid or blood. Vesicles are less than 0.5 cm (0.2 in). Example: Herpes simplex, early chicken pox, small burn blister. Bullae are larger than 0.5 am (o.2 in.). Example: large than  DIGITAL MUCOUS CYST A 1-cm (0.4in.). Or larger, elevated, encapsulated, fluid- filled or semisolid mass arising from the subcutaneous tissue or dermis. Examples: sebaceous and epidermoid cysts, chalazion of the eyelid  “WHEAL” ALLERGIC WHEALS, URTICARIA Redened, localized collection of edema fluid; irregular in shape. Size varies. Examples: hives, mosquito bites  SKIN SECONDARY: THOSE WHO DO NOT APPEAR INITIALLY BUT RESULTS FROM MODIFICATION SUCH AS CHRONICITY, TRAUMA, OR INFECTION OF THE PRIMARY LESIONS. 1. ATROPHY OF THE SKIN Occurs in epidermis, thinning of the outermost layer of the skin-EPIDERMIS -A dermis-middle layer of the skin -STRIAE, AGED SKIN  SKIN SECONDARY: 2. EROSION -Wearing away of the superficial epidermis causing a moist, shallow depression. Because erosions do not extend into the dermis. They heal without scarring. Examples: Scratch marks, ruptured vesicles SKIN SECONDARY 3. LICHENIFICATION- Rough, thickened, hardened area of resulting from chronic irritation epidermis. Examples: Chronic dermatitis  SKIN SECONDARY 4. SCALES- Shedding flakes of greasy, keratinized skin tissue. Color may be white, gray or silver. Texture may vary from fine to thick. Examples: dry skin, dandruff, Psoriasis  SKIN SECONDARY 5. CRUST- Dry blood, serum or pus left on the skin surface when vesicles or pustules burst. Can be red-brown, orange or yellow. Large crust that adhere to the skin surface are called scrabs. Examples: ECZEMA, IMPETIGO, HERPES, OR SCRABS FOLLOWING ABRASION SKIN SECONDARY 6. ULCER- Deep irregular shaped area of skin loss extending into the dermis or subcutaneous tissue. May bleed. May leave scar. Examples: pressure ulcers, stasis ulcers, chancres  SKIN SECONDARY 7. FISSURE- Linear crack with sharp edges, extending into the dermis. Examples: cracks at the corners of the mouth or in the hands, athlete’s foot  SECONDARY 7. SCAR- Flat, irregular area of connective tissue left after a lesion or wound has healed. New scars SKIN may be red or purple: older scars may be silvery or white. Examples: healed surgical wound or injury, healed acne. SKIN SECONDARY 8. KELOID- Elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. Extends beyond the site of the original injury. Higher incidence in people of African descent. Examples” keloid from ear piercing or surgery. SKIN SECONDARY: EXCORIATION- SCRATCHES, SOME CHEMICAL BURNS  SKIN 5. PALPATES LESIONS Palpating a lesion means feeling it with your fingers. -SIZE: how big is it? -SHAPE: Is it round, irregular? -TEXTURE: Is it smooth, rough, firm, soft, or rubbery? -MOBILITY: Can it be moved around easily, or is it fixed in place -TENDERNESS: Does it hurt? When you press on it?  SPECIFIC PALPATION MANEUVERS: AUSPITZ SIGN Scraping the scales of a psoriatic plaque can cause bleeding points, known as the Auspitz sign.  SPECIFIC PALPATION MANEUVERS: NIKOLSKY SIGN -Lateral pressure on a bulla in pemphigus or Stevens-Johnson syndrome can cause the epidermis to detach from the dermis, known as the Nikolsky sign.  DIMPLE SIGN/FITZPATRICK’S SIGN Dimple Sign- Pressing on the sides of a dermatofibroma can cause a dimple, known as the dimple sign. Dermatofibromas are common, benign, fibrous skin tumors that typically appear as firm, brown, or skin-colored nodules. They are often found on the legs, but can occur anywhere on the body. SKIN 6. PALPATES TEXTURE -(ROUGH, SMOOTH) USING PALMAR SURFACE OF THREE MIDDLE FINGER. RATIONALE: Palpation allows healthcare professionals to feel for subtle changes in skin texture that may not be readily apparent visually. This can help differentiate between various skin conditions; SCALING,TEXTURE CHANGES, TEMPERATURE  PALPATES TEXTURE USING THREE MIDDLE FINGER 7. PALPATES TEMPERATURE Check if it is COOL, WARM, HOT, AND MOISTURE (DRY, SWEATY, OILY) OF SKIN, USING DORSAL SIDE OF HAND. Rationale: We use the dorsal (back) surface of the hand to palpate for temperature because the skin on the back of the hand is thinner and more sensitive to temperature changes compared to the palm. 8. PALPATES THICKNESS OF THE SKIN WITH FINGERPADS We use our finger pads to palpate skin thickness for several reasons: SENSITIVITY PRECISION ADAPATABILITY What to look when palpating skin thickness? ✓ Normal skin ✓ Thickened Skin ✓ Thinned Skin  9. PALPATES MOBILITY AND TURGOR Palpating skin mobility and turgor can help differentiate between various skin conditions and identify underlying medical problems. Skin mobility - refers to the skin's ability to move freely over the underlying tissues. Assessment -To assess skin mobility, gently lift a fold of skin and observe how easily it moves. SIGNIFICANCE: ✓ DECREASED MOBILITY-edema, inflammation ✓ INCREASED MOBILITY- loose skin  Palpates mobility and turgor Palpating skin mobility and turgor are valuable clinical skills that provide insights into a patient's overall health and can help identify potential medical issues. These assessments are quick, non-invasive, and can be readily incorporated into routine physical examinations  10. PALPATES FOR EDEMA, PRESSING THUMBS OVER FEET OR ANKLES EDEMA-PRESENCE OF EXCESSFLUID IN INTERSTITIAL SPACE. ANASARCA- GENERALIZED EDEMA Assess if present (location, color, temperature, shape and the degree to which the skin remains indented or pitted when pressed by a finger. Measuring the circumference of the extremity with a millimeter tape maybe useful for future comparison. GRADING OF PITTING EDEMA +1 2MM DEPRESSION, IMMEDIATE REBOUND +2 4MM DEEP PIT; 10-12S TO REBOUND +3 6MM DEEP PIT; 10-12S TO REBOUND +4 MM VERY DEEP PIT;>20S TO REBOUND Scalp and Hair Assessment Step 5: Inspection Step 6: Palpation Inspect the client's scalp and hair for color, amount, Palpate the scalp and hair to assess thickness, texture, distribution, and any signs of lesions or parasites. oiliness, and any signs of lesions or parasites. This step helps identify potential scalp conditions or hair abnormalities. SCALP AND HAIR ASSESSMENT 1. INSPECTS COLOR -Check for the hair color -Hair color is faded and appears red, texture is course and dry (KWASHIORKOR-severe protein deficiency.) SCALP AND HAIR ASSESSMENT: 2. Inspect evenness of growth over the scalp. PATCHES OF HAIR LOSS (ALOPECIA). SCALP AND HAIR ASSESSMENT: 3. Inspect thinness and thickness -VERY THIN HAIR E.G., IN HYPOTHYROIDISM 4. Inspect hair texture and Oiliness- Brittle hair (e.g., in hypothyroidism, excessively oily or dry hair. SCALP AND HAIR ASSESSMENT: 5. Note presence of infections/ infestations by parting the hair in several areas, checking behind the ears and along the hairline at the neck. Flaking, sores, lice and ringworm. SCALP AND HAIR 6. Inspect amount of body hair. Hirsutism (excessive hairiness in women); naturally absent or sparse leg hair (poor circulation). Nail Assessment Grooming and Cleanliness Color and Markings Inspect the client's nails for Inspect the nails for color and any grooming and cleanliness. Note any markings. Look for discoloration, signs of dirt, debris, or improper lines, or other changes that may trimming. indicate underlying health issues. Shape Texture and Consistency Inspect the nails for shape. Note any Palpate the nails to assess texture and signs of clubbing, pitting, or other consistency. Note any signs of abnormalities that may point to brittleness, thickening, or other medical conditions. abnormalities.  NAIL 1. INSPECT FOR GROOMING AND CLEANLINESS. THE “window” to overall health  NAIL 2. INSPECT FOR COLOR AND MARKINGS. Indicates: oxygen deprivation, circulatory problems, congenital problems Red fingernails-possible brain hemorrhage, heart disease, high blood pressure  NAIL 3. INSPECTS SHAPE- inspected for nail plate shape, angle between the fingernail and the nail bed, texture, nail bed color and the intactness of tissues around the nails  NAIL CLUBBING- : a condition in which the angle between the nail and the nail bed is 180 degrees, or greater; (caused by long -term lack of oxygen NAIL excessively thick nails: presence of poor circulation or in relation to chronic fungal infection excessively thin nails: (or the presence of grooves or furrows) can reflect prolonged iron-deficiency anemia Beau’s lines: horizontal depression in the nail that can result from injury or severe illness  NAIL CYANOSIS AND PALLOR both signs of altered blood flow and oxygenation, but they indicate different underlying issues.  NAIL ONYCHOMYCOSIS Fungal infection; symptoms of brittleness, discoloration, thickening, distortion of nail shape, crumbling of the nail, loosening /detaching of the nail Capillary Refill Test Perform the capillary refill test to assess the client’s peripheral circulation. Gently press on the client’s fingernail until it blanches. Release the pressure and observe how quickly the color returns. Normal capillary refill is less than 2 seconds.