Unit 3 Skin Hair and Nails Assessment 2024 PDF

Motivational Activity 1. Please form three groups (a, b, and c - based on where you are seated). 2. Word : – SKIN, – HAIR, and – NAIL 3. Please use the letters of each word to form a sentence describing it. For example, L O V E – living out valuable emotions.  UNIT 3: ASSE...

Motivational Activity 1. Please form three groups (a, b, and c - based on where you are seated). 2. Word : – SKIN, – HAIR, and – NAIL 3. Please use the letters of each word to form a sentence describing it. For example, L O V E – living out valuable emotions.  UNIT 3: ASSESSMENT OF HEALTH STATUS (SYSTEMATIC APPROACH) Skin, Hair & Nail Assessment PRESENTED BY: MRS. KERON JONES-FRASER, PHD CANDIDATE, MSCN, BSCN, CERT ED, RN OBJECTIVES ◦ At the end of three hours adult learners will :  Outline the preparation of the client for assessment  Describe the normal findings of assessing skin, hair and nails  Explain how the skin, hair and nails of clients are assessed Skin, Hair and Nail Assessment Preparation  Ensure that environment is appropriate and conducive (including privacy, lighting and ventilation)  Have necessary equipment on hand at the start of the assessment  Ensure client’s comfort (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin, Hair and Nail Assessment Procedure  Introduce self and verify the client’s identity  Explain intended procedure to client and the importance of doing this assessment  Perform hand hygiene and observe appropriate infection control procedures (for example, donning gloves, if necessary – examiner may be exposed to drainage while palpating lesions). Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin, Hair and Nail Assessment Procedure  Ask client to remove all clothing and jewellery and put on examination gown. Provide for client privacy and expose only the body part to be examined.  Ask client to remove wigs, toupees, hairpieces, nail enamel or artificial nails.  Place client in appropriate position Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin, Hair and Nail Assessment  Assessment of the skin, hair and nails involves the gathering of subjective and objective data. ◦ Interviewing the client seeks to garner subjective data including:  History of present complaint (C O L D S P A)  Past health history  Family history  Lifestyle and health practices (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin, Hair and Nail Assessment C O L D S PA  Character – Describe the sign/symptom. How does it feel, look, smell?  Onset – When did it begin?  Location – Where is it? Local or generalized?  Duration – How long does it last? Does it recur? (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin, Hair and Nail Assessment  Severity – How bad is it?  Pattern – What makes it better? What makes it worse?  Associated factors – What other symptoms occur with it? (Weber & Kelley, 2007) Skin, Hair and Nail Assessment  Sample questions: ◦ Describe any skin problems being experienced including rashes, lesions, dryness, oiliness, drainage, bruising, swelling or increased pigmentation? ◦ What aggravates the problem? ◦ What relieves it? (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin, Hair and Nail Assessment  Sample questions continued: ◦ Has the colour, size or shape of any birthmarks, tattoos or moles changed? ◦ Are you experiencing any pain, itching, tingling or numbness? ◦ Is there any change in your ability to feel pain, pressure, light touch, or temperature? (Kozier, Erb, Berman & Snyder, 2008) (Weber & Kelley, 2007) Skin, Hair and Nail Assessment  Sample questions continued: ◦ Have you ever received treatment including surgery for any problems with your skin? ◦ Have you ever had allergic skin reactions to medications, plants, food or other substances? ◦ Has anyone in your family recently had any illness, rash or other skin problem or allergy? If yes, please describe? ◦ Do you spend long hours in the sun? (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin, Hair and Nail Assessment  Sample questions continued: ◦ Have you ever had any hair loss or change in the condition of your hair? If yes, please describe. ◦ Have you had any change in the condition or appearance of your nails? If yes, describe. ◦ Are you regularly exposed to chemicals including paint, bleach, cleaning products, petroleum? (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin, Hair and Nail Assessment Objective data gathering involves inspection and palpation. ◦ Equipment needed:  Examination light  Penlight  Mirror for client’s self-examination of skin  Magnifying glass  Centimetre ruler  Gloves  Wood’s light  Examination gown or drape (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin Assessment  Inspection, examine the skin for: ◦ General colouration  Normal findings – evenly coloured skin tone  Abnormal findings –  Pallor – loss of colour, pale skin without underlying pink  cyanosis – lighter skin appears blue-tinged, darker skin appears blue and dull  jaundice – skin, sclera, oral mucosa, palms and soles appear yellow  acanthosis nigricans – roughening and darkening of skin in localized areas especially the neck posteriorly Skin Assessment  Abnormal findings: Pallor https://www.google.com.jm/search?rlz=1C1EKKP_enJM741JM742&biw=1366&bih=662&tbm=isch&sa=1&ei=zTqUWrHCC- rs5gLAualA&q=pallor&oq=pallor&gs_l=psy-ab.3..0i67k1j0l2j0i67k1l2j0j0i67k1j0l3.726295.729484.0.730116.14.10.0.0.0.0.417.1080.1j5j4- 1.8.0....0...1c.1.64.psy-ab..6.7.1078.0...142.Hb82_E7GHko Skin Assessment  Abnormal findings:  Jaundice Cyanosis https://www.google.com.jm/search?q=cyanosis&rlz=1C1EKKP_enJM741JM742&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjrn8vmhMTZAh WMuVkKHW9dAq8Q_AUICigB&biw=1366&bih=662 Skin Assessment  Abnormal findings: Acanthosis nigricans https://www.google.com.jm/search?rlz=1C1EKKP_enJM741JM742&biw=1366&bih=662&tbm=isch&sa=1&ei=OD6UWsbRK4y55gLRvKWwDQ&q=Acanthosis+nigricans&oq=Aca nthosis+nigricans&gs_l=psy-ab.12...235655.316097.0.318412.12.12.0.0.0.0.180.840.0j6.9.0....0...1c.1j2.64.psy-ab..3.6.839.0..0j0i67k1.92.jEWrm4WI96A Skin Assessment  Inspection, examine the skin for:  Colour variations  Normal findings – Suntanned areas freckles – flat, small macules of pigment. Skin Assessment  Inspection, examine the skin for:  Colour variations  Normal findings – Vitiligo - depigmentation, Striae - due to the destruction of melanocytes. https://www.google.com.jm/search?rlz=1C1EKKP_enJM741JM742&biw=1366&bih=662&tbm=isch&sa=1&ei=xcOUWuu7GfHP5gKV2YLABA&q=striae+african+american&oq=st riae+african+american&gs_l=psy-ab.3...0.0.1.1845.0.0.0.0.0.0.0.0..0.0....0...1c..64.psy-ab..0.0.0....0.5e19WbF4Qfg#imgrc=WGkl_6tG-wss2M: Skin Assessment  Inspection, examine the skin for:  Colour variations  Abnormal findings – Rashes (reddish in light-skinned persons or darkened in dark- skinned Albinism (generalized loss of pigmentation) Erythema (redness and warmth of the skin seen in inflammation, trauma or allergic reactions (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin Assessment  Colour variations  Rashes Albinism Erythema Skin Assessment  Inspection, examine the skin for:  Skin integrity ◦ (Pay close attention to pressure points. In obese clients ensure the inspection of the skin in the groin, under breasts)  Normal findings – Intact skin with no reddened areas  Abnormal findings – skin breakdown, or reddened areas (early sign of skin breakdown) (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin Assessment  Inspection, examine the skin for:  Pressure ulcers stages https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=zm2442 Skin Assessment  Inspection, examine the skin for:  Lesions (abnormal growth or appearance compared to surrounding skin) normal findings - absence of lesions, smooth skin (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin Assessment  Palpation, examine the skin for: ◦ The palmar surface of the three middle fingers are used  Texture  Normal findings – skin is smooth and even  Abnormal findings – rough, flaky https://www.google.com.jm/search?q=rough+flaky+skin&rlz=1C1EKKP_enJM741JM742&source=lnms&tbm=isch&sa=X&ved=0ah UKEwjI5q7UnsTZAhXSrFkKHVSkAEoQ_AUICigB&biw=1366&bih=662 Skin Assessment  Palpation, examine the skin for: ◦ The thumb and finger are used  Thickness normal findings - Thin skin and calluses in pressure areas abnormal findings - Very thin skin occurs with arterial insufficiency and steroid therapy (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin Assessment  Palpation, examine the skin for:  Moisture  Normal findings – moist to dry depending on area of skin being assessed and the warmth of the environment Abnormal findings – profuse sweating (diaphoresis), clammy skin, decreased moisture as in dehydration (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin Assessment  Palpation, examine the skin for:  Temperature ◦ The dorsal surfaces of hands are used normal findings - skin is warm abnormal findings - skin is cold as in shock or hypotension (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin Assessment  Palpation, examine the skin for: ◦ Mobility and Turgor  Asses by having client lie down and gently pinch the skin on the sternum or below the clavicle.  Normal findings – skin immediately returns to original position after being pinched. (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin Assessment  Palpation, examine the skin for: Abnormal findings – decreased mobility as seen in oedema, slow return to original position after being pinched (poor turgor) (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) https://www.google.com.jm/search?rlz=1C1EKKP_enJM741JM742&biw=1366&bih=662&tbm=isch&sa=1&ei=D1CUWvnGG8jm5gKeh7DQBA&q=poor+skin+turgor+of+the+chest&oq=poor +skin+turgor+of+the+chest&gs_l=psy-ab.3...35745221.35746882.0.35747698.7.7.0.0.0.0.294.529.2-2.2.0....0...1c.1.64.psy- ab..5.0.0....0.aIfUqkdp1_Q#imgdii=JPndrAKG3Z8nTM:&imgrc=bY1QX14WNgNUxM: Skin Assessment Oedema normal findings - skin rebounds and does not remain indented when pressure is released abnormal findings - indentations on the skin is may vary from slight to great (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Skin Assessment Oedema Grading Scale (Kozier, Erb, Berman & Snyder, 2008) (Weber & Kelley, 2007) https://www.google.com.jm/search?rlz=1C1EKKP_enJM741JM742&biw=1366&bih=662&tbm=isch&sa=1&ei=I96UWpzsK8rb5gLk66zgDg&q=edema+pit ting+stages&oq=edema+pitting+stages&gs_l=psy-ab.3..0.26391.31971.0.32887.17.15.0.0.0.0.525.2468.2-5j2j0j1.8.0....0...1c.1.64.psy- ab..9.7.2088...0i8i30k1.0.PJABAtklmrA#imgrc=Xivm5LfzLrsghM: Skin Assessment  Fill in the blanks 1. _e_e_a Accumulation of fluid in body tissues, which may cause swelling 2. _l_s_i_c__y Refers to the skin's ability to stretch and return to normal after being stretched 3. Pa__o_ Describes paleness, lack of colour 4. Mo__li_y Describes how easily skin can be pinched  Skin Assessment  Fill in the blanks 5. __an_s_s Refers to a bluish cast to the skin and mucous membranes 6. T_r__r Refers to skin’s elasticity and the promptness of its return to its original shape after being pinched 7. __y_he__ Refers to skin redness 8. __ess__e _l_er Refers injuries to skin and underlying tissue resulting from prolonged force on the skin Skin Assessment  Fill in the blanks - solution 1. Oedema Accumulation of fluid in body tissues, which may cause swelling 2. Elasticity Refers to the skin's ability to stretch and return to normal after being stretched 3. Pallor Describes paleness, lack of colour 4. Mobility Describes how easily skin can be pinched 5. Cyanosis Refers to a bluish cast to the skin and mucous membranes 6. Turgor Refers to skin’s elasticity and the promptness of its return to its original shape after being pinched 7. Erythema Refers to skin redness 8. Pressure ulcer Refers injuries to skin and underlying tissue resulting from prolonged force on the skin Hair Assessment  Inspection, examine the scalp and hair for:  General colour and condition  Procedure – separate hair at 1-inch intervals and inspect the hair and scalp  Normal findings – natural hair colour varies among clients from pale blond to black to grey or white.  Abnormal findings – Nutritional deficiencies may cause hair colour changes such as patchy grey to copper-red hair colour (Kozier, Erb, Berman & Snyder, 2008) (Weber & Kelley, 2007) Hair Assessment  Inspection, examine the scalp and hair for:  Amount and distribution of hair Vellus hair refers to pre pubertal hair. Terminal hair is thick, strong, pigmented hair that is fully matured. Normal findings - Fine vellus hair covers the entire body except for soles, palms, lips and nipples. Terminal hair of the scalp, axillary, body and public areas occur in varying amounts according to normal gender distribution (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Hair Assessment  Inspection, examine the scalp and hair for:  Amount and distribution of hair Abnormal findings - excessive generalized hair loss (may be due to infection, illness, nutritional deficiencies, drug toxicity, chemotherapy and radiation therapy (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Hair Assessment  Palpation, examine the scalp and hair for: ◦ Cleanliness, dryness or oiliness, parasites and lesions  Procedure – separate hair at 1-inch intervals and inspect and palpate the hair and scalp  Normal findings – scalp is clean and dry, sparse dandruff may be visible. Hair is smooth, firm, has some degree of elasticity (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Hair Assessment  Palpation, examine the scalp and hair for: Abnormal findings – excessive scaliness raised lesions, dull dry hair poor hygiene (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Nail Assessment  Inspection, examine nails for:  Cleanliness and grooming  Normal findings – nails are clean and trimmed  Abnormal findings – dirty, broken, or jagged fingernails may result from poor hygiene or the client’s occupation or hobby (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Nail Assessment  Inspection, examine nails for:  Colour and markings Normal findings – pink tones, some longitudinal ridging, and freckles or pigmented streaks may be present in dark- skinned clients (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Nail Assessment  Inspection, examine nails for:  Colour and markings Abnormal findings – pale, cyanotic nails may indicate hypoxia or anaemia splinter haemorrhages may be caused by trauma Beau’s lines present after acute illness Yellow discoloration may be due to fungal infections or psoriasis (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Nail Assessment  Inspection, examine nails for:  Colour and markings pale, cyanotic nails splinter haemorrhages https://www.google.com.jm/search?biw=1366&bih=662&tbm=isch&sa=1&ei=ruiUWvCAI-TA5gLejY-QAw&q=pale+cyanotic+nail&oq=pale+cyanotic+nail&gs_l=psy- ab.3...261985.275777.0.276292.38.24.0.0.0.0.633.4571.0j11j4j1j1j2.20.0....0...1c.1.64.psy-ab..19.14.3342.0..0j0i67k1j0i8i30k1j0i24k1.440.Zw- ZbvdNHFQ#imgrc=sRTxrW8wnB2ylM: Nail Assessment  Inspection, examine nails for:  Colour and markings Beau’s lines Yellow discoloration https://www.google.com.jm/search?biw=1366&bih=662&tbm=isch&sa=1&ei=3uqUWu6dIo-e5gKT46XYAQ&q=yellow+nail&oq=yellow+nail&gs_l=psy- ab.3..0j0i67k1l4j0l5.84402.88728.0.91422.12.10.0.0.0.0.607.1134.2-2j5-1.3.0....0...1c.1.64.psy- ab..9.3.1133...0i7i30k1j0i30k1j0i8i30k1.0.RHKKBumzWu0#imgrc=UEYxuxaPJChSWM: Nail Assessment  Inspection, examine nails for:  Shape  Normal findings – 160-degree angle between the nail base and the skin is normal  Abnormal findings – 180-degree angle with a spongy sensation (early clubbing) >180-degree angle (late clubbing) may result from hypoxia spoon nails (concave) may be present in iron deficiency anaemia (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Nail Assessment Nail Assessment  Palpation, examine nails for:  Texture and consistency ◦ Normal findings - nails are smooth, firm and firmly attached to nailbed Abnormal findings – Paronychia (inflammation) Detachment of nail from nail bed (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Nail Assessment  Palpation, examine nails for:  Capillary refill ◦ Normal findings – pink tone returns immediately to blanched nail beds when pressure is released ◦ Abnormal findings – Slow return (greater than 2 seconds) of pink tone to blanched nail beds when pressure is released (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) References Kozier, B., Erb, G., Berman, A, & Snyder, S. (2018). Fundamentals of nursing: Concepts, processes, and practice. Pearson Prentice Hall. Weber, J., & Kelley, J. (2018). Health assessment in nursing. Lippincott, Williams & Wilkinson