chapter 11—skin, hair, and nails assessment. copyright © 2015 wolters kluwer all rights reserved...

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  • Chapter 11Skin, Hair, and Nails Assessment

    Copyright 2015 Wolters Kluwer All Rights Reserved

    Integumentary SystemIncludes: skin, hair, nails, sweat glandsProvides vital information about patient health statusOffers systemic data regardingThermoregulatory; endocrine; respiratoryCardiovascular; gastrointestinal; neurologicalUrinary; immuneReflects statusHydration; nutrition; emotional

    Copyright 2015 Wolters Kluwer All Rights Reserved

    Structure and FunctionSkinEpidermis: outermost layer of skin; has five layersFunction: first line of defense against pathogensDermis: second layer of skin; has two layersFunction: supports epidermisContainsBlood vessels; nerves; sebaceous glandsLymphatic vessels; hair follicles; sweat glands

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    Structure and Function(cont.)Skin(cont.)Subcutaneous layer: fat, loose connective tissueFunction: provides insulation; caloric reserve storage; cushioningContributes to skin mobilityHairFunctionProtects specific body areas; provides insulationEnables sensory communication to the nervous system; contributes to gender identification

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    Structure and Function(cont.)Hair(cont.)Vellus hairFine, short, hypopigmentedLocated throughout bodyTerminal hairDarker, coarserLocated on scalp, brows, and eyelidsPostpubertal: axillae, perineum, legsPostpubertal males: chest, abdomen

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    Structure and Function(cont.)Hair(cont.)Composed of keratinProduced by hair follicles, deep in the dermisPresent: all body areas, except palms and solesArrector pili muscles responsively contractStimuli: environmental; nervousAlso known as goosebumpsSebaceous glandsSecrete sebum to maintain moisture, condition

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    Structure and Function(cont.)Nails: epidermal appendageSome systemic diseases, infectious processes can affect nail growth rate, thickness.Sweat glandsFunction: thermoregulationEccrine glands: cover most of body; most numerous in palms, solesOpen directly onto skin

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    Structure and Function(cont.)Sweat glands(cont.)Function: thermoregulation(cont.)Apocrine glands: located in axillae, genital areasOpen into hair follicles; activate at pubertyMilky sweat + bacterial flora = musky odorSebaceous glands: located throughout body, except palms, solesSecrete sebum: moisture retention, friction protectionInflammation of glands may result in acne.

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    Structure and Function Overview(cont.)

    Figure 11.1

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    Lifespan Considerations: Older AdultsEffects of aging on integumentThinner skin: loses elastin, collagen, subcutaneous fatDecreased resilience; sagging/wrinkling; increased visibility; fragile superficial vascular structuresDecreased melatonin; hair follicle atrophy Nail growth slowsNails thin, exhibit increased brittleness

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    Cultural ConsiderationsCultural variationsBecoming familiar with cultural variations facilitatesCommunication; accurate assessmentNecessary patient educationAfrican AmericansKeloid formation; Traction alopecia; pseudofolliculitis; folliculitis barbae; perineal follicularisIncreased melasma in pregnancy; Mongolian spotsSkin is commonly dry ashy dermatitis.

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    AsianSoutheast Asian men: less body, facial hair CommonTattoos, body piercings, other skin adornmentsRarely found outside Asian populationsHori nevus; nevus of OtaHenna tattoos: Arabic, Indian females Common Arabic lesions: Mongolian spots; caf au lait spots; congenital neviCultural Considerations(cont.)

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    Urgent AssessmentPrompt evaluation; interventions/repairAcute dehydration, cyanosis, or acute lacerations (impaired skin integrity)Not usually emergentSuspicious lesions: concern about cancerRash + fever: infectious process?Acute trauma, burnsMay require immediate attentionLarge area: urgent; potentially life-threatening

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    Assessment of risk factorsGeneral health; personal historyMedications; risk factorsRisk assessment and health promotionSkin self-assessmentSSE procedurePatient education regardingLimiting excessive UV radiationCharacteristics of normal/problematic molesSubjective Data Collection

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    Common SymptomsCommon integumentary symptomsPruritus (itching)RashSingle lesion/woundLifespan considerations: older adultCultural considerations

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    QuestionIs the following statement true or false?

    An Arabic woman comes to the clinic for the first time. One of the cultural considerations the nurse must take into consideration is that a chaperone must be in the room when this woman is assessed.

    Copyright 2015 Wolters Kluwer All Rights Reserved

    Answer True

    Rationale: Cultural variations can include a refusal from a patient to remove his or her head covering or a requirement for the patient to have a chaperone present during the examination, particularly if the examiner is not the same sex as the patient.

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    Objective DataCommon and specialty or advanced techniquesComplete skin assessment: head-to-toeMore common: affected body area onlyCharacteristics: color; texture; moisture; turgor; temperatureAssess/describe alterations during focused assessment.Objective data collectionEquipment needed; preparation

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    Comprehensive Skin AssessmentInspectionReposition bedbound patient to visualize all body surfacesPriority areas: bony prominences; skin foldsCategorize lesionsPrimary (arise from normal skin)Maculae; papules; nodules; tumors; polyps; wheals; blisters; cysts; pustules; abscessesSecondary (follow primary lesions)Scar tissue; crusts (from dried burns)

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    Comprehensive Skin Assessment(cont.)PalpationAssessTemperatureTurgorHairLifespan considerations: older adultsCommon skin assessment findingsIncreased risk for abnormal: ecchymoses/purpuric lesions; skin cancer

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    Critical ThinkingIntegumentary alterations often reflect status of other systems.Laboratory and diagnostic testingScraping: microscopic examinationCulture and sensitivity: Identify infective lesions or exudate.Wood light: scalp infectionsBiopsy: diseases which manifest lesion changesColor, size, shape

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    Diagnostic ReasoningNursing diagnosis, outcomes, and interventionsCritical thinking: cluster data; identify patterns Assessment data: identify outcomes (partial list)Skin, mucous membranes are intact.Patient reports no altered sensation or pain at site.Patient demonstrates measure to protect, heal skin.Interventions: Improve patients status (partial list).Assess skin, risk for skin breakdown.Evaluate: efficacy of interventions to achieve outcomes.

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    QuestionYou are caring for an 82-year-old male patient who has been hospitalized after a fall. A family member asks the nurse how often his or her father should bathe. What is the nurses best answer?A. Twice dailyB. DailyC. Every 2 to 3 daysD. Weekly

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    AnswerC. Every 2 to 3 daysRationale: Elderly patients need to bathe less often, usually every 2 to 3 days.