Chapter 14 Assessing Hair, Skin, and Nails Lecture Objectives PDF

Chapter 14 - Assessing Hair, Skin, and Nails Lecture Objectives Describe the structure and function of the skin, hairs and nails. ● ● ● Skin: largest organ of the body; physical barrier that protects the underlying tissue and organs from microorganisms, physical trauma, UVR, and dehydration ○ Tem...

Chapter 14 - Assessing Hair, Skin, and Nails Lecture Objectives Describe the structure and function of the skin, hairs and nails. ● ● ● Skin: largest organ of the body; physical barrier that protects the underlying tissue and organs from microorganisms, physical trauma, UVR, and dehydration ○ Temperature maintenance, 1st line of defense against infections, receives stimuli from environment ○ Fluid and electrolyte balance ○ Absorption, excretion, sensation, immunity, and vit D synthesis ○ Thicker on palms of hand and feet bc of extra layer of the epidermis ○ 3 layers of skin: epidermal, dermal, subcutaneous tissue ■ Epidermis: outer layer of skin; stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum (only layer to undergo cell division and contains melanin) ● Epidermal layer almost completely replaced every 3-4 weeks ● Melanin - color here ■ Dermis: dermal papillae connect the dermis to the epidermis, fingerprints, well-vascularized, CT layer containing collagen, elastic fibers, nerve endings, and lymph vessels; origin of sebaceous glands, sweat glands, and hair follicles ● Sebaceous glands attached to hair follicles and secrete oily substance that waterproofs the hair and skin ● Sweat glands: eccrine and apocrine ○ Eccrine all over skin and secrete sweat and thermoregulation ○ Apocrine small and non functional until puberty (associated with menstrual cycle) ■ Found in armpit, perineal, and areola of breast ■ Subcutaneous: loose CT containing fat cells, blood vessels, nerves, and remaining portions of sweat glands and hair follicles ● Tissue stores fat as energy reserve, provides insulation, serves as cushion to protect bones and internal organs ● Vascular pathways for supply of nutrients and removal of waste products to and from skin Hair ○ Keratinized cells that develop within sheath of epidermal cells called the follicle ■ Not found in lips, nipples, feet, palms, labia minora, and penis ○ Type of hair: vellus and terminal ■ Vellus: short, pale, fine, and present all over body, AKA peach fuzz ● Provide thermoregulation by removing sweat from body ■ Terminal: longer, darker, and coarse that is initiated by puberty ● Scalp, armpits, nasal, eyelashes, ears (filter out dust and debris) ● Insulation, protection Nails: transparent plates of keratinized epidermal cells that grow from cuticle ○ Normal: Hard, transparent, grow from cuticle, pink 1 ○ Protects the distal ends of fingers and toes, enhance precise movement of digits, allow for extended grip Discuss evidence-based promotion and disease prevention: MRSA infections, Skin cancer and Pressure ulcers MRSA ● ● ● ● ● Skin or wound becomes infected with MRSA Greatest risk factor for MRSA is impaired skin integrity ○ Break in the skin somewhere- defense is loss MRSA risk factors ○ Impaired skin integrity ○ Hospital-acquired ■ Invasive medical device or procedure ● Surgery, catheter ■ Residing in long-term care facility ■ Present of MRSA-positive person in facility- pt or employee ○ Community-acquired MRSA risk factors ■ Participating in contact sports ■ Sharing personal items (ex: towels and razors) ■ Immunosuppression (cancer, HIV, very young, very old) ■ Unsanitary or crowded living (college dorm, prisons, military barracks) ■ Working in healthcare industry ■ Abx in past 3-6 months (more use → leaving strong bacteria behind) ■ young/advanced age ■ Men having sex with men ■ Hemodialysis ○ Reducing risk factors for MRSA ■ If you start Abx do not stop them, finish them ■ If in contact sports, clean after use ■ Cover wounds ■ Do not share personal items ■ Universal precautions when touching others and bodily fluids ■ Wash hands often ● Hand sanitizer good, but access to soap and water is always preferable ■ Healthy nail care and practice ■ Wash clothes, sheets, towels, razors, and other personal items before and after use Nursing Interventions ○ Contact precautions → MRSA is spread by direct contact! ○ Monitor closely for signs of further infection- redness, warmth, fever, swelling ○ Keep an eye on equipment used for them Education ○ Hygiene ○ Personal belongings - keep to yourself ○ Look for signs and symptoms ○ Antibiotic education - consistent use and FINISH antibiotics even if symptoms go away Skin Cancer ● 3 types → Melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC) ○ BCC & SCC are nonmelanoma → Meaning they do not arise from melanocytes ■ BCC is the most common form ○ Melanoma can have precursors → Benign or dysplastic nevi (mole) 2 ○ ● ● ● ● SCC can have precursors → Actinic (sun) keratoses or SCC in situ (only in epidermal layer, has not spread) ■ Will be rough and scaly ■ Associated with overall amount of sun exposure Skin cancer risk factors ○ Medical ■ Medical therapies using UV or radiation ■ Actinic keratoses ■ Pigmentation abnormalities- albinism or burn scars ■ HPV ■ Xeroderma pigmentosum (very rare, inherited condition) ■ long-term skin inflammation or injury ■ Bowen disease (scaly or thickened patch) ○ Modifiable ■ Inadequate niacin in diet ■ Smoking ■ Alcohol ■ Sun (skin) exposure ● Dark skin people need skin protection ● When patients with deeper skin tones are diagnosed skin cancer, it’s more advanced ■ Nonsolar sources of UVR- Sunbathing and tanning ○ Non-modifiable ■ Age ■ Fair skin that burns or freckles easily, light hair, light eyes ■ Family history ■ Depressed immune system ■ Male, esp white men over 50 ■ Moles (large, weird, uneven, etc) ■ Chemical exposure Assessment ○ Basal cell carcinoma ■ Waxy nodule, pearly borders ■ Papule, red, central crater ○ Squamous cell carcinoma ■ Oozing, bleeding, crusting lesion ○ Melanoma ■ Irregular, circular, bordered lesion w/ hues of tan, black, or blue Actinic keratoses → Caused by chronic sun exposure to sun (pictured) ○ Rough, scaly, red or brown lesions on face, scalp, arms, backs of hands (areas of body exposed to sun a lot) ○ Premalignant! Nursing Interventions ○ Educate!! → Risk factors & prevention! ○ Teach how to do monthly skin assessment & to monitor lesions that do not heal or change characteristics ○ Sun protection: ■ Layered clothing ■ Sunscreen (reapply) ■ Avoid sun between 10am and 4pm Pressure Ulcers ● ● ● Major cause of morbidity and mortality Most significant contributing factors → Unrelieved pressure, friction and shear Occur more frequently in critical care, long-term care facilities, and in patients at high risk 3 ● ● ● ● ● (prolonged bed rest) Early assessment can lead to the key element of prevention! SCREENING → Complete skin inspection on admission and a minimum of once every 8 to 12 hours thereafter Risk factors ○ Immobility - might be due to poor health, spinal cord injury and other causes. ○ Incontinence - Skin becomes more vulnerable with extended exposure to urine and stool and other moisture ■ Products to protect barrier (clear plastic film to decrease the breakdown) ○ Lack of sensory perception - Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of warning signs and the need to change position ○ 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, can increase the risk of tissue damage such as bedsores ■ Prolonged pressure to body, especially bony prominences ■ decreased/absent perception or sensation ■ decreased/absence mobility ■ Increased moisture ■ increased/decreased nutrition ■ Friction or shearing factors ■ Fragile tissues and skin due to age, vascular incompetence, diabetes mellitus, or body weight (excessive or underweight) ○ On bony areas with little or no subcutaneous tissue ■ Occipital - pillow or pad ■ Ear ■ Scalp ■ Elbow ■ Sacrum ■ Greater trochanter ■ Heels ■ Pt lying flat How to prevent ○ Assess daily ○ Dry skin - want to use moisturizer ○ If red area, do not rub ○ Warm water instead of hot water ○ Turn every two hours in bed ○ Reposition every 15 minutes - chair ○ If patient needs dietician call a consult ○ Bathe with mild soap or other agent, limit friction, use warm not hot water ○ Ambulate if/when possible ○ Educate about good nutrition ○ Incontinence wipes if available Education ○ For Bed- or Chair-bound Clients ■ Self-reposition every 15 minutes (chair) or 2 hours (bed). ■ Use a repositioning schedule. ■ Use a pressure mattress or chair cushion. ■ Use lifting devices as directed to reduce shear (trapeze bar for patient; lifts for family, if necessary). ■ Use positioning with pillows or wedges to avoid bony prominence contact with surfaces and to maintain body alignment; avoid donut-type devices. 4 ■ ● For those who are bed bound, avoid elevating head of bed beyond 30 degrees except for brief periods. ○ Provide structured teaching for patient, family, and caregivers as necessary Intervention ○ Prevention → proper positioning, adequate nutrition, hygiene, skin assessment Skin Assessment (full table on p. 10-12 of this Google Doc) ● ● ● Subjective Data ○ Self care behaviors ○ Hx of skin disease ○ Medications ○ Environmental or occupational hazards ○ Exposure to toxic substances ○ Changes in skin color or pigmentation ○ Change in mole or sore that does not heal Objective Data → Using inspection & palpation ○ Color ○ Temperature → Hypothermia, hyperthermia? ○ Excessive dryness or moisture? ○ Skin turgor ○ Texture → Smoothness, firmness? ○ Excessive bruising? ○ Itching? ○ Rash? ○ Hair loss (alopecia) ○ Nail abnormalities → Pitting (psoriasis) ○ Lesions → May be inspected w/ magnifier, light, Wood’s light ○ Scars, birthmarks ○ Edema ○ Capillary refill → Should be less than 3 seconds Quick Review ○ Cyanosis - blue, decreased oxygen ○ Erythema - red (infection, inflammation) ○ Pallor - pale (anemia, shock) ○ Jaundice - yellow (too much bilirubin) → liver problem Differentiate between normal and abnormal findings specifically related to a macule, plaque, vesicle, pustule, cyst and wheal ● ● ● Maculae ○ Small, flat, non palpable skin color change ○ Macules are less than 1 cm w/ a circumscribed border ○ Ex: freckles, flat moles Plaque ○ Outer skin on epidermis, elevated ○ Plaques are greater than 0.5 centimeters and may be coalesced papules with a flat top ○ Ex: psoriasis and actinic keratosis Vesicles 5 ○ ○ ○ ○ ● ● ● ● Lesion filled with serous fluid on outer skin layer, visible, looks like blister Less than 0.5 centimeters Honey exudate from vesicle → impetigo Ex. of vesicles include herpes, simplex/zoster, varicella, poison ivy, and second degree burns, contact dermatitis Wheal ○ elevated mass with transient borders and no fluid cavity. ○ Outer skin ○ Elevated mass with transient borders that is often irregular, temporary ○ Size and color vary ○ Caused by movement of serous fluid into the dermis ○ Does NOT contain free fluid in a cavity ○ Ex. urticaria (hives) and insect bites (mosquito bite) Pustule ○ Fluid-filled sac or lesion ○ Pus-filled vesicle or bulla ○ Ex. acne, impetigo, furuncles, carbuncles Cyst ○ Not on outer, underneath skin tissue ○ Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis ○ Ex.sebaceous cyst and epidermoid cyst Secondary skin lesions ○ Winter - chapped lips (fistula) ○ Scars have healed, keloid ○ Pressure ulcers ○ Vascular skin lesions ■ More blood-filled, red/blue Describe assessment findings seen with older client’s skin, hair and nails. ● ● ● ● ● ● ● ● ● ● Perspiration decreases with aging Decreased flexibility and mobility may impair the ability of some elderly patients to maintain proper hygiene practices, such as nail cutting/bathing/hair care Older patient skin may become pale from decreased melanin production and decreased dermal vascularity Older patient may have skin lesions associated with aging (seborrheic or senile keratoses, senile lentigines - liver spots, cherry angiomas, purpura, and cutaneous tags and horns), NOT cancerous ○ May see actinic keratoses, but that is abnormal and should be referred ASAP (sign of malignancy) Skin may feel dryer than younger patients bc sebum production decreases with age Skin loses turgor from loss of elasticity and collagen fibers Sagging appears in face, breast, and scrotal areas As patients age, hair may feel coarser and drier along with thinning hair and slow growth ○ Start becoming gray or white Older patients have thinner hair from decrease in follicles ○ Pubic, axillary, and body hair decrease with aging ○ Alopecia seen esp in men, starting from outside working way in ○ Hair loss occurs from the periphery of scalp and moves to center ○ Older women have terminal hair growth on the chin from hormonal changes Nails may appear thickened, yellow, and brittle bc of decreased circulation in extremities 6 Dark Skinned Patient Consideration (added in, but VERY important to know as a nurse) ● ● ● ● Cyanosis ○ Check lips & tongue for a gray color ○ Check nail beds, palms, and soles for a blue color ○ Check conjunctiva for pallor Jaundice ○ Check oral mucous membranes for yellow color ○ Check the sclera nearest to the iris for a yellow color Bleeding ○ Check for skin swelling and darkening. ○ Always compare to unaffected side Inflammation ○ Check for warmth, shiny or taut and pitting skin area ○ Always compare to unaffected side Describe the ABCDE assessment criteria and pressure ulcer staging. ● ● ABCDE assessment of moles ○ A: asymmetry ○ B: borders that are irregular ○ C: colors variation ○ D: diameter exceeding ¼ in or 6 mm ○ E: evolving/evolution Pressure Ulcer staging (Braden Scale last page) ○ https://www.youtube.com/watch?v=xNH8DDvjSME&feature=youtu.be Stage 1 ● ● ● Skin intact Red, does not blanch with external pressure Painful, firm, soft, warmer or cooler than adjacent tissue Stage 2 ● ● ● Skin NOT intact Partial thickness, loss of dermis Shallow open ulcer w/ red-pink wound bed OR intact or open/ruptures serum filled blister Stage 3 ● ● ● ● Full thickness skin loss extends into dermis & subQ tissue Slough may be present SubQ tissue may be visible Undermining or tunneling may be present Stage 4 ● ● ● ● Full thickness skin loss w/ exposed bone, tendon, or muscle Slough or eschar may be present Undermining or tunneling may be present Know this chart, know this chart, know. this. chart. Go back and memorize it! Now! 7 ● ● Other types of pressure injury ○ Deep tissue injury ■ Ischemic subQ tissue injury under intact skin ■ Purple or maroon colored ■ Pain, firm boggy ○ Unstageable ■ Full thickness tissue loss ■ Wounded bed covered by slough or eschar Categories of Braden scale ● “MS. MANS” ➔ M - mobility ➔ S - shear ➔ M - moisture ➔ A - activity ➔ N - nutrition ➔ S - sensory Skin, Hair and Nails Assessment ● PHI ○ ○ ○ ● Have you had this lesion or is it new? Family Hx of lesions/cancer? Lifestyle and health practices ■ How much sun and chemical exposure? ○ How do you care for hair skin and nails ■ Ex: ● Shower daily ● Moisturizer ● Trimmed nails ● No chemicals in hair ● Do not self examine skin daily ** keep this in mind if pt says ● 3 meals, Sufficient exercise ■ Skin is one big organ and skin will probably go along with other systems Equipment ○ Examination light ○ Pen light ○ Mirror for self-examination ○ Magnifying glass ○ Centimeter ruler ○ Gloves ○ Wood light ○ Examination gown or drape ○ Braden scale for predicting pressure sore risk ○ Pressure Ulcer Scale for healing (PUSH) tool to measure healing 8 Skin assessment Assessment Procedure Normal Abnormal Skin Inspect general skin coloration Even, no discoloration Pallor Cyanosis may cause white skin to appear blue-tinged; dark skin may appear blue, dull, lifeless lips, nose, cheek, ears Jaundice - yellow from elevated bilirubin Hard palate and sclera Note any odors Slight or no odor Strong odor of perspiration, foul odor may indicate disorder of sweat glands Color variations Suntan marks, freckles, and vitiligo patches all normal Rashes, butterfly rash from SLE Skin integrity Skin intact, no reddened areas Skin breakdown initially noted as reddened area on skin that may progress to serious and painful; pressure ulcers (will use Braden scale for pressure sore risk) Inspect for lesions If lesion detected, note: ● Symmetry, borders, shape, color, diameter, change over time ● Location, distribution, configuration ● Measure with cm ruler Skin is smooth without lesions; striae, healed scars, freckles, moles, or birthmarks all common findings Lesions may indicate local or systemic problems; Primary lesions arise from normal skin from irritation or disease; Secondary lesions arise from changes in primary lesions; Vascular lesions seen with bleeding, venous pressure, aging, liver disease, or pregnancy Palpate skin to assess texture and thickness using palmar surface of 3 middle fingers Skin is smooth and even; calluses normal and common Rough, flaky, dry skin; very thin skin; infected lesions may be tender to palpate (nonmobile, fixed lesions may be cancer) Palpate to assess temperature Warmth, moisture, texture, tender to touch Use dorsal of hand Cold skin, very warm skin Palpate to assess mobility and turgor Skin is mobile with elasticity and returns to original shape quickly Decreased mobility seen with edema; decreased turgor seen in dehydration (pinch above clavicle) Palpate to detect edema Skin rebounds and does not remain indented Indentations on skin may vary from slightly to great and may be 9 in one area or all over body Scalp and Hair Inspect scalp and hair for general color and condition Scalp is clean (parasites) and dry; sparse dandruff may be visible; hair is smooth and firm, somewhat elastic, color of scalp- white but not red 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 ; poor hygiene may indicate need for patient teaching or assistance with ADLs Varying amounts of terminal hair cover the scalp, axillae, body, and pubic areas according to normal gender distribution. Fine vellus hair covers the entire body except for the soles, palms, lips, and nipples. Normal male pattern balding is symmetric Excessive generalized hair loss may occur with infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure. It may also result from chemotherapy or radiation therapy; Patchy hair loss may result from infections of the scalp, discoid or systemic lupus erythematosus, and some types of chemotherapy.; Hirsutism (facial hair on females) is a characteristic of Cushing disease and polycystic ovary syndrome (PCOS) and results from an imbalance of adrenal hormones or it may be a side effect of steroids Inspect nail grooming and cleanliness; nail color and markings; shape Nails are cleaned and manicured; pink tone with some longitudinal ridging; may have freckles or pigmented streaks in nails in darker-skin patients; normally 160-degree angle between nail base and skin Dirty, broken, jagged nails from poor hygiene or from hobby/occupation; pale cyanotic nails from hypoxia or anemia; clubbing from hypoxia (remember diamond shape); nail spooning from anemia; assess capillary refill should be less than 2-3 seconds Palpate to assess texture, consistency (noting if plate attached to bed); test capillary refill by squeezing quickly Hard and basically immobile; smooth and firm; pink tone returns quickly Thickened nails (esp toenails) from decreased circulation and with onychomycosis; inflammation from local At 1-inch intervals, separate the hair from the scalp and inspect and palpate their hair and scalp for cleanliness, oiliness/dryness, parasites, and lesions Inspect amount and distribution of scalp, body, axillae, and pubic hair. Look for unusual growth elsewhere on the body. Nails 10 infections; detachment of plate from bed seen with infections or trauma; slow capillary refill from respiratory, cardiovascular disease that cause hypoxia Beau’s lines - recent illness Define specific diagnostic procedures (tests) related to skin assessment: Braden scale ● ● Braden Scale ○ The lower the number the higher the risk Six categories within the Braden Scale: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. ○ The resident is scored on a scale of 1-4 in the categories below: ○ 1: Completely limited ○ 2: Very limited ○ 3: Slightly limited ○ 4: No impairment 11 Braden Scale 4 3 2 1 Sensory perception No impairment - no sensory deficit that would impair ability to feel/voice discomfort Slightly limited - responds to verbal commands, but cannot always communicate discomfort; limited ability to feel in 1 or 2 extremities Very limited - responds only to painful stimuli; cannot communicate discomfort except for moaning or restlessness; limits feeling pain in over ½ of body Completely limited unresponsive; does not moan/flinch/gasp to painful stimuli from diminished LOC, sedation, or limited ability to feel pain over most of body surface Moisture Rarely moist Skin usually dry; linen only requires changing as usual Occasionally moist - skin occasionally moist, requiring linen change once a day Often moist - skin often but not always moist; linens changed once a shift Constantly moist - skin kept moist constantly by urine or perspiration, dampness detected every time pt it moved or turned Activity No limitations - walks outside room at least 2x/day; inside room every 2 hr Walks occasionally - walks sometimes during day, but very short distances and spends majority of shift in bed or chair Chairfast - ability to walk severely limited or impaired, cannot bear own weight and must be assisted into chair/wheelchair Bedfast - confined to bed Mobility No limitations - makes frequent changes in position without assistance Slightly limited - makes frequent though slight changes in body or extremity position independent Very limited - makes occasional slight movement in body/extremity position Completely immobile - does not make even slight changes in body or extremity position without assistance Nutrition Excellent - eats most of every meal; never refuses; does not require supplementation Adequate - eats over half of meal; total of 4 servings of protein in a day; occasionally refuse supp/meal; may be on tube feeding but meets requirements Probably inadequate rarely eats a complete meal and generally only eats about ½ of any food; only 3 servings of protein a day; occasionally takes supplement; receives less than optimum amount of diet from tube feeding Very poor - never eats full meal; rarely eats more than ⅓ offered; 2 servings or less of protein; takes fluids properly; does not take any supplement; OR is NPO or maintained on IV/full liquid for more than 5 days Friction & Shear 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 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 Problem - requires moderate to max assistance; constant friction Risk scale None (19-23) Mild (15-18) Moderate (13-14) High (10-12) Severe (6-9) You do not need to add up points and diagnose a pressure ulcer like some prepU questions, but you need to need to know the categories, how to interpret a given score, etc. 12