recent_Health_Assessment_skin_hair_nails_Final_prof_wafaa_2023_2024.pps

Health Assessment Skin, Hair, and Nails Prepared by Prof./ Wafaa Hassan Abdullah Medical Surgical Nursing Faculty of Nursing Menoufia university 2023-2024 After completing lecture , the student will be able to...

Health Assessment Skin, Hair, and Nails Prepared by Prof./ Wafaa Hassan Abdullah Medical Surgical Nursing Faculty of Nursing Menoufia university 2023-2024 After completing lecture , the student will be able to: 1. Verbalize the steps used in performing selected examination procedures in assessing the skin., hair, and nails. 2. Describe suggested sequencing to conduct a physical health examination in an orderly fashion. 3. Discuss variations in examination techniques appropriate for clients of different ages. 4. Demonstrate appropriate documentation and reporting of health assessment. 08/02/24 prof. Wafaa Hassan 2  ASSESSMENT OF THE INTEGUMENTARY SYSTEM Skin Nails Hair Part 1. Anatomical Parts of the Skin 08/02/24 prof. Wafaa Hassan 3  Assessing the Skin, Skin 08/02/24 prof. Wafaa Hassan 4  INTEGUMENT ” skin-hair-nails” 08/02/24 prof. Wafaa Hassan 5  SKIN COLOR Normal Deviations from Varies from light Normal Pallor to deep brown, Cyanosis from ruddy pink Jaundice to light pink Erythema 08/02/24 prof. Wafaa Hassan 6 Pallor 08/02/24 prof. Wafaa Hassan 7 Cyanosis Cyanosis (a bluish tinge) is most evident in the nail beds, lips, and buccal mucosa. In dark-skinned clients, close inspection of the palpebral conjunctiva (the lining of the eyelids) and palms and soles may also show evidence of cyanosis. 08/02/24 prof. Wafaa Hassan 8  Erythem a It is skin redness associated with a variety of rashes and other conditions. Localized areas of hyperpigmentation (increased pigmentation) and hypopigmentation (decreased pigmentation) may occur as a result of changes in the distribution of melanin (the dark pigment) or in the function of the melanocytes in the epidermis. 08/02/24 prof. Wafaa Hassan 9  Skin Color Uniformity Normal Deviations Deviations Generally uniform Hyperpigmentation Hypopigmentation except in areas exposed Birthmarks – Vitiligo due to to sun; areas of lighter abnormal destruction of pigmentation in dark distribution of the melanocytes in the area skinned melanin Albinism – complete or partial lack of melanin 08/02/24 prof. Wafaa Hassan 10 08/02/24 prof. Wafaa Hassan 11  3. Assess for Edema Excessive accumulation of fluid in body tissues Note the degree to which the skin remains indented or pitted when pressed by a finger Edema scale 1+ = barely detectable 2+ = indentation of less than 5 mm 3+ = indentation of 5 to 10 mm 4+ = indentation of more than 10 mm ANASARCA 08/02/24 prof. Wafaa Hassan 12  ANASARCA Where is anasarca edema? 08/02/24 prof. Wafaa Hassan 13 Edema 08/02/24 prof. Wafaa Hassan 14 08/02/24 prof. Wafaa Hassan 15 Inspect, palpate, and describe skin lesions According to type/structure, color, number, distribution, location TYPES: Primary skin lesions – abscess, ulcer, tumor, and open wound 08/02/24 prof. Wafaa Hassan 16  PRIMARY SKIN LESIONS 08/02/24 prof. Wafaa Hassan 17 Secondary skin lesion  crusts, kelloids, scars, Cyst etc. 08/02/24 prof. Wafaa Hassan 18 Observe and palpate skin moisture Palpate skin temperature Done by touching or palpating the skin of the extremities Normal Deviations Normal Deviations within normal Generalized or Moist Excessively dry range localized; hyperthermic/ hypothermic 08/02/24 prof. Wafaa Hassan 19 Palpate Skin Turgor Refers to fullness or elasticity Indicative of status of hydration of the body. Assessed by pinching the skin on an extremity. Normal Deviations When pinched, skin Skins stays pinched or springs back to indented or moves back slowly. previous state in less than 3 seconds 08/02/24 prof. Wafaa Hassan 20  Note that: this is not as valid in elderly people as in younger people because skin elasticity decreases with age; thus, other parameters should be used, such as: I&O, daily weight 08/02/24 prof. Wafaa Hassan 21  Assessing the nails 08/02/24 prof. Wafaa Hassan 22  1. Inspect fingernail plate shape, curvature & angle Normal Deviations from Normal – Colorless and a convex Concave curve. Clubbed fingernails (>180 o) – Angle between nail and due to chronic tissue hypoxia nail bed: usually, 160o 08/02/24 prof. Wafaa Hassan 23  Examples of Nail Abnormalities 08/02/24 prof. Wafaa Hassan 24  2. Inspect and palpate finger & toenail bed color Normal Deviations from Normal Highly vascular and pink in Bluish or purplish light tinges; skinned; dark skinned may be Pale brown or black 08/02/24 prof. Wafaa Hassan 25  3. Inspect tissues surrounding nails Normal Deviations from N Intact epidermis Hangnails (paronychia = ingrown nail) Inflammation of surrounding tissues 08/02/24 prof. Wafaa Hassan 26  4. Perform Blanch Test/Capillary refill test Normal Deviations Prompt return or pink or Delayed return of pink or usual color, less than 2-4 usual color, usually >4 seconds seconds 08/02/24 prof. Wafaa Hassan 27  Hair abnormalities Now “hair” this: Hair abnormalities may be caused by certain drugs or endocrine problems. 08/02/24 prof. Wafaa Hassan 28  Assessing the Hair 08/02/24 prof. Wafaa Hassan 29 08/02/24 prof. Wafaa Hassan 30 Hirsutism Alopecia Alopecia occurs more commonly and extensively in men than in women. Diffuse hair loss, though commonly a normal part of aging, may occur as a result of pyrogenic infections, chemical, trauma, ingestion of certain drugs, and endocrinopathy and other disorders. Tinea capitis, trauma, and full- thickness burns can cause patchy hair loss. 08/02/24 prof. Wafaa Hassan 31 Normal Deviations from Normal Evenly Patches of hair loss, i.e. distributed Alopecia Normal Thick Hair 08/02/24 prof. Wafaa Hassan 32 Normal Deviations from Normal Silky, resilient hair Brittle hair (poor nutrition) excessively oily or dry hair Deviations from Normal Normal Flaking, sores, lice, nits No infection/ infestation 08/02/24 prof. Wafaa Hassan 33  References Weber,R.J,Kelley.H.J(2018):HealthAssessmentinNursing,6thed.Philade lphia:LippincottWilliams&Wilkins Kozier&erb’s. (2016).FundamentalsofNursing,concepts,process,andpractice.10th ed. Jarvis, C. (2012) Physical examination & health assessment. 6th Edition, Elsevier Saunders, St. Louis. 08/02/24 prof. Wafaa Hassan 34 08/02/24 prof. Wafaa Hassan 35