Skin, Hair, and Nails Assessment (TWU) PDF

Skin Cancer • Most common of cancers • Three types: melanoma (most serious) , basal cell carcinoma, squamous cell carcinoma (not lifethreatening) • Asians are less susceptible Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer True. Sebum has some fungicidal and bactericidal effects....

Skin Cancer • Most common of cancers • Three types: melanoma (most serious) , basal cell carcinoma, squamous cell carcinoma (not lifethreatening) • Asians are less susceptible Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer True. Sebum has some fungicidal and bactericidal effects. TRUE Copyright © 2018 Wolters Kluwer · All Rights Reserved Risk Factors of Skin Cancer (cont.) • Male gender • Chemical exposure • Human papillomavirus • Xeroderma pigmentosum • Long-term skin inflammation or injury • Alcohol intake; smoking • Inadequate niacin in diet • Bowen disease (scaly or thickened patch) (SCC) • Depressed immune system Copyright © 2018 Wolters Kluwer · All Rights Reserved Risk Reduction in Skin Cancer • Reduce skin exposure. • Always use sunscreen when sun exposure is anticipated. • Wear long-sleeve shirts and wide-brimmed hats. • Avoid sunburns. • Wear sunglasses that wrap around. • Understand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on developing cancers. • Have annual skin cancer screenings. • M Copyright © 2018 Wolters Kluwer · All Rights Reserved Risk Reduction in Skin Cancer (cont.) • Ensure that diet is adequate in vitamin B3 (niacin). • Examine the skin for suspected lesions using the ABCDE mnemonic to assess suspicious lesions: – Asymmetry – Border – Color – Diameter – Evolution (changes over time) Copyright © 2018 Wolters Kluwer · All Rights Reserved Question Which skin disorder may be caused by exposure to the sun? A. Acne B. Cancer C. Vitiligo D. Warts Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer B. Cancer. Skin cancer may be caused by exposure to the sun. Acne, vitiligo, and warts are not caused by sun exposure. Copyright © 2018 Wolters Kluwer · All Rights Reserved Cultural Variations in Skin Cancer • Asians are less susceptible to skin cancer • African Americans, Asians, and Hispanics are susceptible to melanoma • Asian Americans and African Americans tend to present with more advanced disease at diagnosis Copyright © 2018 Wolters Kluwer · All Rights Reserved Risk Factors for Methicillin-Resistant Staphylococcus aureus • Assess for hospital-acquired MRSA risk factors: – Having an invasive medical device – Residing in a long-term care facility – Presence of an MRSA-positive person in the facility Copyright © 2018 Wolters Kluwer · All Rights Reserved Risk Factors for Methicillin-Resistant Staphylococcus aureus (cont.) • Assess for community-acquired MRSA risk factors: – Participating in contact sports – Sharing personal items such as towels or razors – Suppression of immune system function (e.g., HIV, cancer, or chemotherapy) – Residing in unsanitary or crowded living conditions (e.g., dormitories or military barracks) Copyright © 2018 Wolters Kluwer · All Rights Reserved Risk Factors for Methicillin-Resistant Staphylococcus aureus (cont.) – Working in the health care industry – Receiving antibiotics within the past 3 to 6 months – Young or advanced age – Men having sex with men – Hemodialysis Copyright © 2018 Wolters Kluwer · All Rights Reserved Measures to Reduce Risk Factors for Methicillin-Resistant Staphylococcus aureus • Keep wounds covered. • Do not share personal items. • Avoid unsanitary or unsafe nail care practices. • If treatment has been started, do not stop until recovery is complete. • Use universal precautions when touching others to avoid contact with contaminated body fluids. Wash your hands. • Clean sports equipment between uses to avoid spread of infection. • Wash clothes, sheets, towels, razors, and other personal items before and after use. • Clean hands often. Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing History: Present Health Concern • Body odor problems • Skin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation) • Changes in lesion appearance • Feeling changes (pain, pressure, itch, tingling) • Hair loss or changes • Nail changes Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing History (cont.) • Personal health history • Family history • Lifestyle and health practices – Exposure to sun or chemicals – Daily care of skin, hair, and nails – Usual diet and exercise patterns Copyright © 2018 Wolters Kluwer · All Rights Reserved Client Preparation • Ask the client to remove all clothing and jewelry. • Have the client sit comfortably. • Ensure privacy. • Maintain comfortable room temperature. Copyright © 2018 Wolters Kluwer · All Rights Reserved Equipment for Skin, Hair, and Nail Assessment • Gloves • Examination light and penlight • Mirror for client’s self-examination of skin • Magnifying glass • Centimeter ruler • Wood light • Examination gown or drape • Assessment Tool 14-2, Braden Scale For Predicting Pressure Sore Risk • Assessment Tool 14-3, PUSH Tool to Measure Pressure Ulcer Healing Copyright © 2018 Wolters Kluwer · All Rights Reserved Skin Assessment: Inspection • Note any distinctive odor • Generalized color variations • Skin breakdown • Primary, secondary, or vascular lesions Copyright © 2018 Wolters Kluwer · All Rights Reserved Skin Assessment: Palpation • Lesions • Texture • Temperature and moisture • Thickness of skin • Mobility and turgor • Edema Copyright © 2018 Wolters Kluwer · All Rights Reserved Pressure Ulcer Risk Factors • Perception • Mobility • Moisture • Nutrition • Friction or shear against surfaces • Tissue tolerance decreased Copyright © 2018 Wolters Kluwer · All Rights Reserved Pressure Ulcer Risk Reduction • Inspect the skin at least daily and more often if at greater risk using risk assessment tool (such as Braden Scale or PUSH tool) and keep flow chart to document. • Bathe with mild soap or other agent; limit friction; use warm, not hot, water; set bath schedule that is individualized. • For dry skin: use moisturizers; avoid low humidity and cold air. • Avoid vigorous massage. Copyright © 2018 Wolters Kluwer · All Rights Reserved Pressure Ulcer Risk Reduction (cont.) • Use careful positioning, turning, and transferring techniques to avoid shear and friction or prolonged pressure on any point. • Refer nutritional supplementation needs to primary care provider or dietitian, especially if protein deficient. • Refer incontinence condition to primary care provider. • Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products. Copyright © 2018 Wolters Kluwer · All Rights Reserved Scalp and Hair • Inspection and palpation – General color and condition, cleanliness, dryness or oiliness, parasites, and lesions – Amount and distribution of scalp, body, axillae, and pubic hair Copyright © 2018 Wolters Kluwer · All Rights Reserved Nail Assessment • Nails – Inspection: Nail grooming and cleanliness, nail color and markings, shape of nails – Palpation: Assess texture and consistency, capillary refill Copyright © 2018 Wolters Kluwer · All Rights Reserved Nails Risk Factors • Nails in moist environment, especially walking in damp public locales or continuously wearing closed shoes; excessive perspiration • Nail injury, trauma, or irritation • Repeated irritation (especially water, detergents) • Immune system disorders such as diabetes mellitus and AIDS or on immunosuppressive medications • Skin conditions such as psoriasis or lichen • Some trades or professions • Contagion from one digit to another or one person to another • Possibly family predisposition Copyright © 2018 Wolters Kluwer · All Rights Reserved Nails Risk Reduction Tips • Wear leather shoes except for sports. • Avoid wearing closed shoes all the time. • Wear socks that wick away moisture. • Avoid going barefoot in damp public areas. • Avoid too much perspiration or water (wear gloves for hands). • Avoid trauma to nails. • Avoid unsanitary or unsafe nail care practices. • If treatment is started, do not stop until recovery is complete. Copyright © 2018 Wolters Kluwer · All Rights Reserved Physical Assessment • Capillary refill assessment procedure • Hair color and texture – Individuals of African American descent often have very dry scalps and dry, fragile hair. Copyright © 2018 Wolters Kluwer · All Rights Reserved Self-Assessment of Skin, Hair, Nails • Refer to Box 14-1, Self-Assessment: How to Examine Your Own Skin Copyright © 2018 Wolters Kluwer · All Rights Reserved Normal and Abnormal Findings • Share outcomes of skin, hair, and nails assessment with peers Copyright © 2018 Wolters Kluwer · All Rights Reserved Pressure Ulcer Stages • Stage I • Stage II • Stage III • Stage IV • Unstagable Copyright © 2018 Wolters Kluwer · All Rights Reserved Primary Skin Lesions • Macule and patch • Papule and plaque • Nodule and tumor • Vesicle and bulla • Wheal • Pustule • Cyst Copyright © 2018 Wolters Kluwer · All Rights Reserved Secondary Skin Lesions • Erosion • Ulcer • Scar • Fissure Copyright © 2018 Wolters Kluwer · All Rights Reserved Vascular Skin Lesions • Petechia • Ecchymosis • Hematoma • Cherry angioma • Spider angioma • Telangiectasis Copyright © 2018 Wolters Kluwer · All Rights Reserved Common Nail Disorders • Longitudinal ridging • Half-and-half nails • Pitting • Koilonychia • Yellow nail syndrome • Paronychia Copyright © 2018 Wolters Kluwer · All Rights Reserved Validating and Documenting Findings • Health promotion diagnoses • Risk diagnoses • Actual diagnoses • Collaborative problems • Medical problems Copyright © 2018 Wolters Kluwer · All Rights Reserved Common Changes in Aging Skin, Hair, and Nails • Skin – Pale – Skin lesions – Dry – Loses turgor • Hair: Thinner • Nails: Thickened, yellow, brittle Copyright © 2018 Wolters Kluwer · All Rights Reserved