Chapter 13 Lecture(1).pptx

Chapter 13 Skin, Hair, and Nails Copyright © 2020 by Elsevier Inc. All rights reserved.  Culture and Genetics  Genetic attributes of dark-skinned individuals afford protection against skin cancer due to melanin.  Increased likelihood of skin cancer in whites tha...

Chapter 13 Skin, Hair, and Nails Copyright © 2020 by Elsevier Inc. All rights reserved.  Culture and Genetics  Genetic attributes of dark-skinned individuals afford protection against skin cancer due to melanin.  Increased likelihood of skin cancer in whites than in black and Hispanic populations  Most important environmental risk factor for skin cancer is exposure to ultraviolet (UV) radiation both from sun and indoor tanning sources.  Increased risk for melanoma r/t increased number of sunburns during one’s lifetime.  Certain skin presentations are associated with different ethnic groups. Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data Health History Questions  Past history of skin disease, allergies, hives, psoriasis, or eczema?  Change in pigmentation?  Change in mole (size or color)?  Excessive dryness or moisture?  Pruritus? Itchiness  Excessive bruising? Pathology driven  Rash or lesions?  Medications?  Hair loss? Alopecia  Change in nails? Good indicator of blood flow  Environmental or occupational hazards?  Patient-centered care? Copyright © 2020 by Elsevier Inc. All rights reserved. Additional Health History Questions  Adolescents  Skin problems such as pimples, blackheads?  Aging adults  What changes have you noticed in your skin in past few years?  Any delay in wound healing?  Any change in feet: toenails, bunions, wearing shoes?  Falling: bruises, trauma?  History of diabetes or peripheral vascular disease? Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence: The Aging Adult  Elasticity  Loses elasticity; skinfolds and sags( most cases as a result of dehydration )  Sweat and sebaceous glands  Decrease in number and function, leaving skin dry  Senile purpura( around the face, arms , feets)  Discoloration due to increasing capillary fragility  Skin breakdown due to multiple factors ie friction, time, lack of circulation.  Cell replacement is slower and wound healing is delayed.  Hair matrix  Functioning melanocytes decrease, leading to gray fine hair Copyright © 2020 by Elsevier Inc. All rights reserved.  Objective Data( data in front of you)  Preparation  Consciously attend to skin characteristics; the danger is one of omission.  Equipment needed  Strong direct lighting, gloves, penlight, and small centimeter ruler Copyright © 2020 by Elsevier Inc. All rights reserved.  Physical Examination  Complete physical examination  Skin assessment integrated throughout examination  Scrutinize the outer skin surface first before you concentrate on underlying structures. Describe as you see it, include drainage, colour, odour.  Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groin, and inspect them thoroughly.  Always inspect feet, toenails, and between toes.  Regional physical examination  Individuals may seek health care for skin problems and assessment focused on skin alone.  Assess skin as one entity; getting overall impression helps reveal distribution patterns. Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection and Palpation: Skin (1 of 3)  Color  General pigmentation, freckles, moles, birthmarks  Widespread color change: Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow)( build up of a lot of bilirubin) Note if color change transient or due to pathology.  Temperature  Use backs of hands to palpate person.  Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status.  Hands and feet may be slightly cooler in a cool environment: Hypothermia Hyperthermia Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection and Palpation: Skin (2 of 3)  Moisture  Diaphoresis( excessive sweating)  Dehydration  Texture  Normal skin feels smooth and firm with even surface.  Thickness  Observe for thickened areas (callus formation).  Edema( water entractment, you press on it ) while lypmhdyma is non compressible.  Assess for fluid accumulation in the interstitial space  Mobility and turgor  Assess skin elasticity  Vascularity or bruising  Assess for presence of tattoos and/or variations Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection and Palpation: Skin (3 of 3)  Lesions( mole, or lump): if any are present, note the following:  Color  Elevation  Pattern or shape  Size  Location and distribution on body.  Any exudate: note color and odor.  Use a Wood’s light (ultraviolet light filtered through special glass) to detect fluorescing lesions. Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection and Palpation: Hair  Color  Due to melanin production  Texture  Characteristics range from fine to thick to curly to straight and may be affected by use of hair care products.  Distribution  Tanner staging identifies gender patterns of hair distribution.  Lesions  Identification by looking at scalp and dividing hair into sections.  Hyperthyrodism affects hair growth and texture. Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection and Palpation: Nails  Shape and contour  Profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees.  Consistency  Observe for smooth, regular, not brittle or splitting, uniform nail thickness.  Color  Translucent nail plate to pink nail bed below.  Note ethnic variations.  Capillary refill  Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation.  For a patient with heart failure cap refill maybe distended. Copyright © 2020 by Elsevier Inc. All rights reserved. Profile Sign: Clubbing, associated with lung disease Copyright © 2020 by Elsevier Inc. All rights reserved.  ABCDEF Skin Assessment  Promoting health and self-care  Teach skin self-examination using ABCDEF rule to detect suspicious lesions A: asymmetry B: border irregularity C: color variations D: diameter greater than 6 mm E: elevation or evolution( the higher the deeper roots) F: funny looking - “ugly duckling” - different from others Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence: Life-Cycle Presentations (1 of 2)  Adolescent  Acne  Open and closed comedones  History of Pregnancy  Striae( stretch marks )  Linea nigra( pigmentation from navel to pubic symphysis)  Chloasma( associated with liver disease)  Vascular spiders( associated with liver disease), pressure also causes this. Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence: Life-Cycle Presentations (2 of 2)  Aging  Skin color and presentations Senile lentigines (Age spots) Keratoses( not cancerous )  Moisture Xerosis( dry skin )  Texture Skin tags or acrochordons  Thickness Thin parchment  Decreased mobility and turgor  Decreased hair growth, nail growth, and brittle nails( all boils down to poor circulation) Copyright © 2020 by Elsevier Inc. All rights reserved.  Detecting Color Changes in Light and Dark Skin  Be aware of normal variations for the following variables:  Pallor( pale)  Cyanosis  Erythema  Jaundice  Brown-tan Copyright © 2020 by Elsevier Inc. All rights reserved.  Annular or Circular fungi infection  Begins in center and spreads to periphery Copyright © 2020 by Elsevier Inc. All rights reserved. Confluent( allergy towards meds or foods)  Lesions run together Copyright © 2020 by Elsevier Inc. All rights reserved.  Discrete( acne)  Distinct and separate Copyright © 2020 by Elsevier Inc. All rights reserved.  Grouped ( itchy)  Cluster of lesions Copyright © 2020 by Elsevier Inc. All rights reserved.  Gyrate( scabies from poor dirty laundered clothes)  Twisted, coiled, or snakelike Copyright © 2020 by Elsevier Inc. All rights reserved.  Target or Iris  Resembles iris of eyes, concentric rings  A deer tick bite( lyme disease) can cause heart disease. Copyright © 2020 by Elsevier Inc. All rights reserved.  Linear  Scratch, streak, line or stripe.  Where it is located is also important eg in terms of violence Copyright © 2020 by Elsevier Inc. All rights reserved.  Polycyclic  Annular lesions grow together. Copyright © 2020 by Elsevier Inc. All rights reserved.  Zosteriform  Linear arrangement following a unilateral nerve route. ( chicken poxshingles) Copyright © 2020 by Elsevier Inc. All rights reserved.  Macule and Patch Macules Solely a color change, flat and circumscribed, less than 1 cm Patches Macules that are larger than 1 cm Copyright © 2020 by Elsevier Inc. All rights reserved.  Papule and Plaque Papules Felt and caused by superficial thickening of the epidermis Plaques Papules coalescing to form surface elevation wider than 1 cm Copyright © 2020 by Elsevier Inc. All rights reserved.  Nodule and Tumor Nodules Solid, elevated, hard or soft, greater than 1 cm that may extend deeper into dermis than papule Tumors Larger in diameter, firm or soft, deeper into dermis, may be benign or malignant Copyright © 2020 by Elsevier Inc. All rights reserved.  Wheal and Urticaria/Hives Wheals Superficial, raised, transient and erythematous, irregular in shape due to edema Urticaria (hives) Wheals coalesce to form extensive pruritic reaction. Copyright © 2020 by Elsevier Inc. All rights reserved.  Vesicle( not so large) and Bulla( Vesicles very large and fluid filled) Elevated cavity containing fluid up to 1 cm (blister) Bullas Larger than 1 cm diameter, usually single chamber, superficial in dermis and ruptures easily Copyright © 2020 by Elsevier Inc. All rights reserved.  Cyst Cysts Encapsulated fluid filled cavity Copyright © 2020 by Elsevier Inc. All rights reserved.  Pustule( acne) Pustules Pus in cavity that is circumscribed and elevated. Copyright © 2020 by Elsevier Inc. All rights reserved.  Crust Crust – ( impetigo and extremely contagious) Thickened dried out exudate Copyright © 2020 by Elsevier Inc. All rights reserved.  Scale Scale Compact flakes of desiccated skin from shedding of dead excess keratin cells Copyright © 2020 by Elsevier Inc. All rights reserved.  Fissure Fissures - Linear crack with abrupt edges extending into dermis. When the skin gets dry due to dehydration. Copyright © 2020 by Elsevier Inc. All rights reserved.  Erosion Erosions Scooped out but shallow depression Copyright © 2020 by Elsevier Inc. All rights reserved.  Ulcer Ulcers Deeper depression extending into dermis with irregular shape, may bleed, leaves scar. 1st stage: area of redness, non blenchable, skin is intact 2nd stage 3rd stage: 4th stage: Copyright © 2020 by Elsevier Inc. All rights reserved.  Excoriation Excoriations Self-inflicted abrasion that is superficial Copyright © 2020 by Elsevier Inc. All rights reserved.  Scar Scars Permanent fibrotic change after healing. Hyperkoloid after a wound is healed. Copyright © 2020 by Elsevier Inc. All rights reserved.  Atrophic Scar Atrophic scars : associated with striae Resulting skin level is depressed with loss of tissue and thinning Copyright © 2020 by Elsevier Inc. All rights reserved.  Lichenification Lichenifications ( leprosy) Prolonged intense scratching leads to thickened skin producing tightly packed set of papules Copyright © 2020 by Elsevier Inc. All rights reserved.  Keloid Keloids Benign excess of scar tissue beyond original injury Copyright © 2020 by Elsevier Inc. All rights reserved.  Pressure Injuries (PI) Pressure Ulcer, Decubitus Ulcer  Stages  Stage I: Non-blanchable( stays red, never turns white) erythema  Stage II: Partial-thickness skin loss( epidermis starting to open up)  Stage III: Full-thickness skin loss  Stage IV: Full-thickness skin/tissue loss  Deep tissue pressure injury (DTI)  PI caused by medical device Copyright © 2020 by Elsevier Inc. All rights reserved.  Vascular Lesions (1 of 2)  Hemangiomas  Port-wine stain (nevus flammeus)  Strawberry mark (immature hemangioma)  Cavernous hemangioma (mature)  Telangiectases( liver disease and radiation therapy)  Spider or star angioma  Venous lake Copyright © 2020 by Elsevier Inc. All rights reserved.  Vascular Lesions (2 of 2)  Purpuric lesions  Petechiae(blood going through the pores pf the skin)  Ecchymosis  Purpura  Ecchymosis( traumatic injury or bruise, heals and goes away) purpura is pathological ie platelet dysfunction  Lesions caused by trauma or abuse:  Pattern injury  Hematoma  Contusion (bruise) Copyright © 2020 by Elsevier Inc. All rights reserved.  Common Skin Lesions  Primary contact dermatitis  Allergic drug reaction  Tinea corporis (ringworm of the body)  Tinea pedis (ringworm of the foot) - Athlete's foot  Labial herpes simplex (cold sores)  Tinea versicolor  Herpes zoster (shingles)  Erythema migrans of lyme disease  Psoriasis Copyright © 2020 by Elsevier Inc. All rights reserved.  Malignant Skin Lesions  Basal cell carcinoma  Squamous cell carcinoma  Malignant melanoma Copyright © 2020 by Elsevier Inc. All rights reserved.