Assessing-Skin-Hair-and-Nails_removed.pdf

Health Assessment Week 5: Course Material V- CONTENTS and DISCUSSIONS ASSESSING SKIN, HAIR and NAILS Structure and Functions The integumentary system consists of skin, hair, and nails, which are external structur...

Health Assessment Week 5: Course Material V- CONTENTS and DISCUSSIONS ASSESSING SKIN, HAIR and NAILS Structure and Functions The integumentary system consists of skin, hair, and nails, which are external structures that serve a variety of specialized functions. THE SKIN  The largest organ of the body  It is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration.  Plays vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.  It is composed of three layers the epidermis, dermis, and subcutaneous tissue. o EPIDERMIS:  The outer layer of the skin is composed of four layers namely: stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum.  The outer most layer consists of dead, keratinized cells that is insoluble in water.  The epidermis, hair, nails, dental enamel, and horny tissues are composed of keratin.  Completely replaced every 3 to 4 weeks.  The innermost layer is the stratum germinativum, the only layer that undergoes cell division and contains melanin (brown pigment) and keratin-forming cells.  Melanin is the major determinant of skin color o DERMIS  The inner layer of the skin, the dermal papillae connects the dermis to the epidermis.  The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, lymph vessels. It is also the origin of sebaceous glands, sweat glands and hair follicles. Assessing Skin, Hair, and Nails 6 Prepared by: Dennis B. Brosola, RN, MSN Health Assessment Week 5: Course Material o SEBACEOUS GLANDS  Are attached to the hair follicles and therefore are present over most of the body, excluding the soles and palms.  Secretes an oily substance called sebum that waterproofs the hair and skin. o SWEAT GLANDS  Eccrine and apocrine glands are two types  The Eccrine glands: are located over the entire skin. The primary function is secretion of sweat and thermoregulation, which is accomplished by evaporation of sweat from the skin surface.  The Apocrine glands: are associated with hair follicles in the axillae, perineum, and areolae of the breasts. The glands are small and non-functional until puberty.  The interaction of sweat with skin bacteria produces a characteristic body odor.  In women apocrine secretions are linked with the menstrual cycle. o SUBCUTANEOUS TISSUE  Located beneath the dermis. A loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.  Stores fats as an energy reserve, provides insulation to conserve internal body heat.  Serves as a cushion to protect bones and internal organs and contains vascular pathways for the supply of nutrients and removal of waste products to and from the skin. Assessing Skin, Hair, and Nails 7 Prepared by: Dennis B. Brosola, RN, MSN Health Assessment Week 5: Course Material HAIR  Consists of keratinized cells found over much of the body except for the lips, nipples, soles of the feet, palms of the hand, labia minora, and penis.  Hair develops within a sheath of epidermal cells called the hair follicle. Hair growth occurs at the base of the follicle, where cells in the hair bulb are nourished by the dermal blood vessels.  The hair shaft is visible above the skin and the hair root is surrounded by the hair follicle. Attached to the hair follicle are the erector pili muscles.  There are two general types of hair: vellus and terminal. Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body. Terminal hair (particularly scalp and eyebrows) is longer, generally darker, and coarser than vellus hair. Puberty initiates the growth of additional terminal hair in both sexes on the axillae, perineum, and legs.  Hair color varies and is determined by the type and amount of pigment (melanin and pheomelanin) production. A reduction in production of pigment results in gray or white hair NAILS  The nails, located on the distal phalanges of fingers and toes, are hard transparent plates of keratinized epidermal cells that grow from the cuticle.  The nail body extends over the entire nail bed and has a pink tinge as a result of blood vessels underneath.  The lunula is a crescent-shaped area located at the base of the nail. It is the visible aspect of the nail matrix.  The nails protect the distal ends of the fingers and toes, enhance precise movement of the digits, and allow for an extended precision grip. Collecting Subjective Data: The Nursing Health History Diseases and disorders of the skin, hair, and nails may be local or caused by an underlying systemic condition. To perform a complete and accurate assessment it is important to collect data about current symptoms, the client’s past and family history, and lifestyle and health practices. The information obtained provides clues to the client’s overall level of functioning in relation to the skin, hair, and nails. Ask questions in a straightforward manner. Keep in mind that a nonjudgmental, sensitive approach is needed if the client has abnormalities that may be associated with poor hygiene or unhealthy behaviors. Also, some skin disorders might be highly visible and potentially damaging to the person’s body image and self-concept. HISTORY OF PRESENT HEALTH CONCERN Question SKIN Ask for skin problems such as rashes, lesions, dryness, oiliness, drainage, bruising, swelling, or changes in skin color? What aggravates the problem? What relieves it? Do you have any birthmarks or moles? If so, please describe them. Have any of them changed color, size, or shape? Have you noticed any change in your ability to feel pain, pressure, light touch, or temperature variations? Are you experiencing any pain, itching, tingling, or numbness? Are you taking any medications (prescribed or “over the counter”), using any ointments or creams, herbal or nutritional supplements, or vitamins? If so, how long have you Assessing Skin, Hair, and Nails 8 Prepared by: Dennis B. Brosola, RN, MSN Health Assessment Week 5: Course Material been taking each of these? Do you have trouble controlling body odor? Do you perceive yourself to have excessive perspiration? HAIR and NAILS Have you had any hair loss or change in the condition of your hair? Describe. PERSONAL HEALTH HISTORY Do you recall having severe sunburns as a child? Describe any previous problems with skin, hair, or nails, including any treatment or surgery and its effectiveness. Have you had any recent hospitalizations or surgeries? Have you ever had any allergic skin reactions to food, medications, plants, or other environmental substances? Have you had a recent viral or bacterial illness? For female clients: Are you pregnant? Are your menstrual periods regular? Do you have a history of self-injury? FAMILY HISTORY Has anyone in your family had a recent illness, rash, or other skin problem or allergy? Describe. Has anyone in your family had skin cancer? Do you have a family history of keloids? LIFESTYLE and HEALTH PRACTICES Do you sunbathe? What is the frequency and duration of sun or tanning-booth exposure? Do you use sun block and if so what type (specify SPF)? Do you perform skin self-examination once a month? In your daily activities, are you regularly exposed to chemicals or irritants that may harm the skin (e.g., coal, tar, pitch, creosote, arsenic compounds, radium, alcohol, hand foam, latex, bleach, peroxide)? Do you spend long periods of time sitting or lying in one position? Do you have any body piercing? Do you have any tattoos? What is your daily routine for skin, hair, and nail care? What products do you use (e.g., soaps, lotions, oils, cosmetics, self-tanning products, razor type, hair spray, shampoo, hair coloring, nail enamel)? How do you cut your nails? What kinds of foods do you consume in a typical day? How much fluid do you drink each day? Do you have a history of smoking and/or drinking alcohol? Do skin problems limit any of your normal activities? Describe any skin disorder that prevents you from enjoying your relationships. Assessing Skin, Hair, and Nails 9 Prepared by: Dennis B. Brosola, RN, MSN Health Assessment Week 5: Course Material SELF- ASSESSMENT: HOW TO EXAMINE YOUR OWN SKIN Collecting Objective Data: Physical Assessment  Physical assessment of the skin, hair, and nails provides data that may reveal local or systemic problems or alterations in a client’s self-care activities.  A separate, comprehensive skin, hair, and nail examination, preferably at the beginning of a comprehensive physical examination, ensures that you do not inadvertently omit part of the examination. Preparing the Client  Remove all clothing and jewelry and put on examination gown  Ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as appropriate.  Have the client sit comfortably on the examination table or bed for the beginning of the examination.  During the skin examination, ensure privacy by exposing only the body part being examined. Make sure that the room is a comfortable temperature Equipment  Examination light  Penlight  Mirror for client’s self-examination of skin  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 pressure ulcer healing Assessing Skin, Hair, and Nails 10 Prepared by: Dennis B. Brosola, RN, MSN  Health Assessment Week 5: Course Material ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS Inspect general skin Inspection reveals evenly PALLOR: (loss of color) is seen coloration colored skin tones without in arterial insufficiency, unusual or prominent decreased blood supply, and discolorations. anemia. Pallid tones vary from pale to ashen without underlying pink. CYANOSIS: may cause white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas. Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction While inspecting skin Client has slight or no odor of A strong odor of perspiration or coloration, note any odors perspiration, foul odor emanating from the skin. depending on activity may indicate disorder of sweat glands Inspect for color variations Common variations include Abnormal findings include suntanned areas, freckles, or rashes, such as the reddish (in white patches known as light-skinned people) or vitiligo. The variations are due darkened (in dark-skinned to different amounts of people) butterfly rash melanin in certain areas. (also called Malar rash) across the bridge of the nose and cheeks. Assess skin integrity Skin is intact, and there are Skin breakdown is initially no reddened areas. noted as a reddened area on the skin that may progress to serious and painful pressure ulcers. Inspect for lesions: Skin is smooth, without Primary lesions arise from Symmetry, borders and lesions. Stretch marks normal skin due to irritation shape, color, diameter of (striae), healed scars, freckles, or disease. lesions and change in lesion moles, or birthmarks are Secondary lesions (arise from over time. common findings. Freckles or changes in primary moles may be scattered over lesions. the Vascular lesions reddish-bluish skin in no pattern. lesions, are seen with bleeding, venous pressure, aging, liver disease, or pregnancy. Cancerous lesions can be either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma Assessing Skin, Hair, and Nails 11 Prepared by: Dennis B. Brosola, RN, MSN  Health Assessment Week 5: Course Material PALPATION Palpate skin to assess Skin is smooth and even Rough, flaky, dry skin is seen in texture. Use the palmar hypothyroidism. Obese clients surface of your three middle often report dry, itchy skin. fingers to palpate skin texture. Palpate to assess thickness. Skin is normally thin but Very thin skin may be seen in calluses (rough, thick sections clients with arterial insufficiency of epidermis) or in those on steroid therapy. are common on areas of the body that are exposed to constant pressure (e.g., the heels). Palpate to assess moisture. Skin surfaces vary from moist Increased moisture or Check under skin folds and in to dry depending diaphoresis (profuse unexposed areas. on the area assessed. Recent sweating) may occur in activity or a warm conditions such as environment may cause fever or hyperthyroidism. increased moisture. Decreased moisture occurs with dehydration or hypothyroidism. Clammy skin is typical in shock or hypotension. Palpate to assess Skin is normally a warm Cold skin may accompany temperature. Use the dorsal temperature. shock or hypotension. surfaces of your hands to Cool skin may accompany palpate the skin arterial disease. Very warm skin may indicate a febrile state or hyperthyroidism. Palpate to assess mobility and Normally, the skin is mobile, Decreased mobility is seen with turgor. Ask the client to lie with elasticity and returns to edema. down. Using two fingers, original shape quickly. Recoil gently pinch the skin over the is usually immediate. clavicle. Mobility: How easily the skin is pinched. Turgor: refers to the skin’s elasticity and how quickly the skin returns to its original shape after being pinched. Palpate to detect edema. Use Skin rebounds and does not Indentations on the skin may your thumbs to press down remain indented when vary from slight to great and on the skin of the feet, ankles, pressure is released. may be in one area or all over or pretibial area to check for the body. edema (swelling related to accumulation of fluid in the tissue). SCALP and HAIR INSPECTION and PALPATION Inspect the scalp and hair for Natural hair color, as opposed Nutritional deficiencies may Assessing Skin, Hair, and Nails 12 Prepared by: Dennis B. Brosola, RN, MSN  Health Assessment Week 5: Course Material general color and condition. to chemically cause patchy gray hair in some Colored hair, varies among clients. Severe malnutrition in clients from pale blond to African black to gray or white. The American children may cause a color is determined by the coppered hair color. amount of melanin present. Excessive scaliness may indicate dermatitis. Raised lesions may indicate infections or tumor growth. Dull, dry hair may be seen with hypothyroidism and malnutrition. Pustules with hair loss in patches are seen in tinea capitis, a contagious fungal disease. Infections of the hair follicle (folliculitis) appear as pustules surrounded by erythema. Inspect amount and Varying amounts of terminal Patchy hair loss may result distribution of scalp, body, hair cover the scalp, axillae, from infections of the scalp, axillae, and pubic hair. body, and pubic areas discoid or systemic lupus according to normal gender erythematosus, and some types distribution. Fine vellus hair of chemotherapy. covers the entire body except for the soles, palms, lips, and Hirsutism (facial hair on nipples. Normal male pattern females) is a characteristic balding is symmetric 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. NAILS INSPECTION Inspect nail grooming and Nails are clean Dirty, broken, or jagged cleanliness fingernails may be seen with poor hygiene. They may also result from the client’s hobby or occupation. Inspect nail color and Pink tones should be seen. Pale or cyanotic nails may markings. Some longitudinal ridging is indicate hypoxia or anemia. normal. Splinter hemorrhages may be caused by trauma. Dark-skinned clients may have freckles or pigmented Yellow discoloration may be streaks in their nails. seen in fungal infections or psoriasis. Nail pitting is also common in psoriasis. Inspect shape of nails There is normally a 160- Early clubbing (180-degree Assessing Skin, Hair, and Nails 13 Prepared by: Dennis B. Brosola, RN, MSN  Health Assessment Week 5: Course Material degree angle between the nail angle with spongy sensation) base and the skin. and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia. PALPATION Palpate nail to assess texture. Nails are hard and basically Thickened nails (especially immobile. toenails) may be caused by decreased circulation and are also seen in onychomycosis. Palpate to assess texture and Nails are smooth and firm; Paronychia (inflammation) consistency, noting whether nail plate should be firmly indicates local infection. nail plate is attached to nail attached to nail bed. Detachment of nail plate from bed. nail bed (onycholysis) is seen in infections or trauma. Test capillary refill in nail Pink tone returns immediately There is slow (greater than 2 beds by pressing the nail tip to blanched seconds) capillary nail bed refill briefly and watching for nail beds when pressure is (return of pink tone) with color change. released. respiratory or cardiovascular diseases that cause hypoxia. Skin Types Classified by their reactions to Ultraviolet Radiation (UVR) Type Definition Description I Always burns but never tans Pale skin, red hair, freckles II Usually burns, sometimes tans Fair skin III May burn, usually tans Darker skin IV Rarely burns, always tans Mediterranean V Moderate constitutional pigmentation Latin American. Middle eastern V1 Marked constitutional pigmentation Black Health Promotion Diagnoses  Readiness for Enhanced Health Management: Skin, hair, and nail integrity related to healthy hygiene and skin care practices, avoidance of overexposure to sun.  Readiness for Health Management: Requests information on skin reactions and effects of using a sun-tanning booth. Risk Diagnoses  Risk for Impaired Skin Integrity related to excessive exposure to cleaning solutions and chemicals.  Risk for Impaired Skin Integrity related to prolonged sun exposure  Risk for Imbalanced Body Temperature related to immobility, decreased production of natural oils, and thinning skin.  Risk for Impaired Skin Integrity of toes related to thickened dried toenails  Risk for Imbalanced Body Temperature related to severe diaphoresis  Risk for Infection related to scratching of rash  Risk for Impaired Nail Integrity related to prolonged use of artificial nails  Risk for Imbalanced Nutrition: less than body requirements related to increased vitamin and protein requirements necessary for healing of a wound  Risk for Infection related to multiple body piercings  Risk for Infection related to periodic skin tattooing Actual Diagnoses Assessing Skin, Hair, and Nails 14 Prepared by: Dennis B. Brosola, RN, MSN Health Assessment Week 5: Course Material  Ineffective Health Maintenance related to lack of hygienic care of the skin, hair, and nails  Impaired Skin Integrity related to immobility and decreased circulation  Impaired Skin Integrity related to poor nutritional intake and bowel/bladder incontinence  Disturbed Body Image related to scarring, rash, or other skin condition that alters skin appearance  Disturbed Sleep Pattern related to persistent itching of the skin  Deficient Fluid Volume related to excessive diaphoresis secondary to excessive exercise and high environmental temperatures Abnormalities of the Skin, Hair and Nails: Common Skin Variations Freckles Vitiligo Pigmentation of Striae the skin Seborrheic keratosis Scar Mole Cutaneous tags Cutaneous horn Cherry angiomas Assessing Skin, Hair, and Nails 15 Prepared by: Dennis B. Brosola, RN, MSN