2. Skin, Hair, Nails - Tagged.pdf

Skin, Hair & Nails Dr. Laura Graafland, DNP, MS, AGPCNP-BC, CBCN Subjective – History/Interview Frank Rodrigues 2 History - Skin Disease  Diabetes, lupus, psoriasis Infectious processes  Herpes zost...

Skin, Hair & Nails Dr. Laura Graafland, DNP, MS, AGPCNP-BC, CBCN Subjective – History/Interview Frank Rodrigues 2 History - Skin Disease  Diabetes, lupus, psoriasis Infectious processes  Herpes zoster Trauma  ecchymosis (bruising), abrasions/lacerations Allergic reactions  Hives Poor wound healing  may be caused by chronic disease such as diabetes or PVD Exposure to irritants  poison ivy, chemicals such as cleaning solutions or dyes UV exposure  sun or tanning beds, sunscreen use Frank Rodrigues Medications  Accutane, topical steroids, retinoids 3 History – Hair & Nails Hair – History of hair disorders (ie alopecia, hirsutism) Nails – History of nail diseases or abnormalities (ie onychomycosis, onycholysis, etc.) Frank Rodrigues 4 Review of Systems - Skin Change in pigmentation Change in mole (size or color) Excessive dryness or moisture Pruritus Excessive bruising Rash, lesions, wounds Environmental or occupational hazards Medications Self-care behaviors Frank Rodrigues 5 Review of Systems – Hair and Nails Increased hair shedding/thinning – Is the hair breaking or coming out at the roots? Hair care practices – Frequency of washing, use of dyes, chemical relaxers, hot tools Recent exposures to head/pubic lice, or other inhabitants Yellowing or cracking of the nails Separation of nails from their beds Habits – Nail biting or nervous nail picking – Hair pulling Frank Rodrigues Typical nail care 6 Analysis of Symptoms O : Onset P : Provocative or Palliative Q : Quality or Quantity R : Region or Radiation S : Severity Scale/Site T : Timing O : Onset L : Location D : Duration C : Character A : Associated/Aggravating Factors R : Radiation Frank Rodrigues T : Timing 7 History - Developmental Considerations Young Children Adolescents Birthmarks? Skin problems like Change in skin color as a acne/blackheads? newborn? Any changes that you’ve noticed in your skin over the last few Have you noted any rash or years? sores? How do you care for your skin? – What seems to bring it on? Does the child have any diaper rash? Older Adults – How do you care for this? Any changes that you’ve noticed – How do you wash diapers? Do you use rubber pants? in your skin over the last few – How do you clean child’s skin? years? How do you care for your skin? Does the child have any burns or Delay in wound healing? bruises? Any skin pain? Exposure to contagious skin Changes in feet/toenails? conditions: scabies, impetigo, Bunions – if so can you wear lice? shoes? Exposure to communicable Do you experience frequent falls? diseases: measles, chickenpox, History of diabetes or PVD Frank Rodrigues scarlet fever? Exposure to toxic plants: poison ivy? Does the child have any habits or habitual movements, e.g., nail 8 Objective – Skin Physical Exam Frank Rodrigues 9 Skin Equipment Preparation needed External Strong direct variables lighting that Small influence centimeter skin color ruler Penlight Frank Rodrigues Gloves 10 Skin – Inspect and Palpate Color General pigmentation Widespread color change Moisture Temperature Texture and Thickness Mobility and Turgor Frank Rodrigues Lesions 11 Color – General Pigment Observe skin tone – Normally even and consistent with genetic background – Varies from: Pink tan to ruddy dark tan Light to dark brown with yellow or olive overtones POC normally have areas of lighter pigment on palms, nailbeds, and lips General pigment may be darker in sun-exposed areas Can be affected by external variables: – Environmental – Emotional Frank Rodrigues – Physical 12 Color – General Pigment Pink Undertones Yellow Undertones Frank Rodrigues 13 Color – Widespread Color Change Pallor Present with anemia, shock or arterial insuffi ciency Common in high stress states which cause vasoconstriction (ie anxiety or fear) Pallor can be observed in mucous membranes, lips and nail beds. The palpebral conjunctiva and nail beds are preferred sites for assessing pallor from Frank Rodrigues anemia 14 Color – Widespread Color Change Frank Rodrigues 15 Color – Widespread Color Change Erythema Intense redness of skin due to excess blood (hyperemia) in dilated superficial capillaries Expected with fever, localized infection or emotional responses If due to fever or inflammation, there is also increased skin temperature (increased blood flow through local blood vessels) Occurs with carbon monoxide poisoning, venous stasis, polycythemia (increased RBC) Frank Rodrigues and bruises 16 Color – Widespread Color Change Erythema with folliculitis Erythema with localized swelling Frank Rodrigues 17 Color – Widespread Color Change Cyanosis Bluish mottled color that signifies decreased perfusion of tissues with oxygenated blood Best seen in very vascular areas with thin overlying epidermis: lips, nose, cheeks, ears, and oral mucous membranes (best under florescent light) Peripheral cyanosis is more difficult to visualize in melanated skin  look for other s/s Occurs with shock, heart failure, chronic bronchitis, congenital heart disease, cardiac arrest, severe COVID-19 infection Frank Rodrigues 18 Color – Widespread Color Change Central Cyanosis Central cyanosis is associated with Frank Rodrigues arterial desaturation and involves the skin, mucous membranes, lips, tongue, and nail beds. 19 Color – Widespread Color Change Jaundice Exhibited by yellow color, indicating rising amount of bilirubin in blood Best assessed in natural daylight First noted in junction of hard and soft palate or in sclera As the level of bilirubin rises, jaundice is evident in the skin over the rest of the body May be accompanied by clay colored stool and dark Frank Rodrigues golden urine 20 Color – Widespread Color Change Decreased Pigmentation Increased Pigmentation Vitiligo is an acquired condition Acanthosis nigricans is with complete absence of characterized by areas of dark, melanin pigment in patchy velvety discoloration in body areas of white or light skin on folds and creases the face, neck , hands, feet, Skin can become thickened body folds, and around orifices. Most often in neck, armpits, and Can occur in all races, although groin darker skinned individuals are Most common in individuals who more severely affected are obese or have diabetes Frank Rodrigues 21 Color – Developmental Considerations Congenital Dermal Melanocytosis Café au lait spot Frank Rodrigues 22 Color – Developmental Considerations Acrocyanosis Cutis Marmorata Frank Rodrigues 23 Color – Developmental Considerations Acne - Comedomal Acne - Pustular Frank Rodrigues 24 Color – Developmental Considerations Seborrheic keratosis Senile lentigines (liver spots) Frank Rodrigues 25 Moisture Perspiration appears normally in response to activity, a warm environment, or anxiety, on the: – Face – Hands – Axillae – Skin Folds Diaphoresis (profuse perspiration) is expected to accompany: – Increased activity – Fever Dehydration may be apparent via: – Dry lips Frank Rodrigues – Dry or cracked mucous membranes Developmental considerations for the older adult: – Number of sweat and sebaceous glands decreases, 26 Temperature Palpate skin with dorsa of hand - check bilaterally Skin should be warm and equal bilaterally – suggesting normal circulatory status Hands and feet may normally be cooler in cool environment Immobilized limbs may also normally be cooler (ie limb in a cast or infusion) Hypothermia - generalized coolness May be induced (surgery or high fever) General hypothermia accompanies shock, cardiac arrest Localized hypothermia occurs in peripheral arterial insufficiency Hyperthermia – generalized increased temperature Occurs with increased metabolic rate (ie heavy activity, fever) A localized area may feel hyperthermic with trauma, infection, Frank Rodrigues sunburn 27 Texture &Thickness Texture- normal is smooth and firm, with even surface Thickness- epidermis is thin over most of body except palms and soles – Atrophic skin (very thin and shiny) occurs with arterial insufficiency Developmental considerations for the older adult – Skin becomes thin like Frank Rodrigues parchment and subcutaneous fat diminishes 28 Abnormalities - Edema Fluid accumulating in the interstitial spaces Grade +1 to +4 Look for cause: Deep venous thrombosis (DVT) Chronic venous insufficiency Lymphedema (usually non-pitting) Frank Rodrigues Orthostatic edema Congestive heart failure 29 Mobility and Turgor Assess by pinching a large fold of skin on the anterior chest under the clavicle or dorsa of hand and then release. Skin should normally be easy to lift and quick to return Mobility Turgor Skin’s ease of rising Ability to return to place Normal rises easily promptly when released Frank Rodrigues Developmental considerations for the older adult: -Turgor is decreased (less elasticity) and the skin tents 30  Lesions – General Approach to Describing When palpating lesions, you can: Assess depth of nodules (roll between thumb and index finger) scrape scale to assess for bleeding check the surrounding skin for temp assess for blanching Wear a glove if you anticipate contact with blood, mucosa, or any body fluid. Specific terminology should be used regarding: Number Size Color Shape Texture Primary Lesion (morphology) Frank Rodrigues Location Configuration Other features (ie exudate, bleeding, odor) 31 Common Shapes/Configurations of Lesions & Rashes Frank Rodrigues 32 Wound Assessment Type: – incision, laceration, skin tear, rash, excoriation or decubitus Appearance: – pink, red, eschar, sloughing, edematous, ecchymosis Dressing: – open to air, changed, sterile, dry , intact with staples, sutures or steri- strips Drainage: – serous, purulent, serosanguinous or Frank Rodrigues none 33  Primary Skin Lesions Refer to table provided in CANVAS for quick reference Frank Rodrigues 34 Macule Flat Circumscribed Non-palpable 1cm) Usually single chambered Superficial in epidermis Thin walled – ruptures easily Ex. Friction blister, burns, contact dermatitis Frank Rodrigues 45  Secondary Skin Lesions Refer to table provided in CANVAS for quick reference Frank Rodrigues 46  Debris on the Skin Surface: Crust Scale Break in the Continuity of the Skin Surface: Fissure Erosion Excoriation Ulcer Miscellaneous: Scar Atrophy Lichenification Frank Rodrigues 47 Crust Thickened, dried residue of burst vesicles, pustules or blood Can be red-brown, honey-colored or yellow depending on the fluid’s origin Ex. eczema, impetigo, crust phase of herpes simplex Frank Rodrigues 48 Scale Compact desiccated flakes of skin Dry or greasy Silvery or white From shedding of dead excess keratin cells Visible exfoliation of the dermis Ex. Tinea pedis Frank Rodrigues 49 Fissure A linear crack with abrupt edges Extends into the dermis Can be dry or moist ex. cheilosis, anal fissure Frank Rodrigues 50 Erosion A superficial loss of epidermis Shallow depression in the skin Moist but no bleeding Usually circumscribed Heals without a scar because does not extend into the dermis Ex. Tru Frank Rodrigues 51  Excoriation A scratch mark Superficial Can be self-inflicted abrasion secondary to intense itching Ex. Scratch from foreign body, insect bites, scabies, dermatitis, varicella Frank Rodrigues 52  Scar Replacement of destroyed normal skin tissue by fibrous connective tissue A permanent change Keloid Scar Hypertrophic scar The resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of Frank Rodrigues original injury Can be pink, red, skin colored or darker than 53 surrounding skin Atrophy Thin skin – often looks shiny and translucent May be dry and fragile/bleed easily Ex. Striae, senile skin, arterial insufficiency Frank Rodrigues 54 Lichenification Thickening and roughening of the skin Usually as a result of intense scratching Results from a tightly packed set of papules Causes increased visibility of the superficial skin markings Ex. long standing eczema, atopic dermatitis Frank Rodrigues 55 Ulcer Lesions on skin or mucous membrane May contain necrotic tissue or slough Can involve the epidermis, Dermis or subcutaneous tissue May contain granulation tissue Ex: pressure ulcers or chancre sores Frank Rodrigues 56 Pressure Ulcers Factors Contributing to Risk: Immobility, excessive pressure Sensory loss Friction and Shear injury Nutritional status, fluid status Moisture, heat, incontinence Co-morbid conditions Developmental considerations for the older adult: Aging skin repairs itself more slowly, so wound healing may be up to 4 times slower which increases risk for pressure Frank Rodrigues ulcers and infections 57 Secondary Skin Lesions: Pressure Ulcers Frank Rodrigues Pressure Ulcers – Assessing Risk with Braden Scale Sensory Activity Moisture Mobility Nutritio Friction Perception n and Sheer 1 Completely Bedfast Constantl Complete Very Poor Problem Limited y Moist ly Immobile 2 Very Limited Chairfast Very Very Probably Potential Moist Limited Inadequa Problem te 3 Slightly Walks Occasiona Slightly Adequate No Limited Occasiona lly Moist Limited Apparent lly Problem 4 No Walks Rarely No Excellent Impairment Mild toFrequentl No Moderate Moist High Impairme Risk Very High Frank Rodrigues Risk y Risk nt Risk 15-23 13-14 10-12 6-9 59 Pressure Ulcers Frank Rodrigues 60 Pressure Ulcers Frank Rodrigues 61 Vascular Lesions 62 Frank Rodrigues Petechiae Pin sized macules that are red in color Formed when capillaries break open