Transcript

Chapter 11—Skin, Hair, and Nails Assessment

Chapter 11—Skin, Hair, and Nails Assessment

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Integumentary SystemIntegumentary System

• Includes: skin, hair, nails, sweat glands

• Provides vital information about patient health status

• Offers systemic data regarding

– Thermoregulatory; endocrine; respiratory

– Cardiovascular; gastrointestinal; neurological

– Urinary; immune

• Reflects status

– Hydration; nutrition; emotional

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Structure and FunctionStructure and Function

• Skin

– Epidermis: outermost layer of skin; has five layers

• Function: first line of defense against pathogens

– Dermis: second layer of skin; has two layers

• Function: supports epidermis

• Contains

• Blood vessels; nerves; sebaceous glands

• Lymphatic vessels; hair follicles; sweat glands

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Structure and Function—(cont.)Structure and Function—(cont.)

• Skin—(cont.)

– Subcutaneous layer: fat, loose connective tissue

• Function: provides insulation; caloric reserve storage; cushioning

• Contributes to skin mobility

• Hair

– Function

• Protects specific body areas; provides insulation

• Enables sensory communication to the nervous system; contributes to gender identification

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Structure and Function—(cont.)Structure and Function—(cont.)

• Hair—(cont.)

– Vellus hair

• Fine, short, hypopigmented

• Located throughout body

– Terminal hair

• Darker, coarser

• Located on scalp, brows, and eyelids

• Postpubertal: axillae, perineum, legs

• Postpubertal males: chest, abdomen

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Structure and Function—(cont.)Structure and Function—(cont.)

• Hair—(cont.)

– Composed of keratin

– Produced by hair follicles, deep in the dermis

• Present: all body areas, except palms and soles

– Arrector pili muscles responsively contract

• Stimuli: environmental; nervous

• Also known as goosebumps

– Sebaceous glands

• Secrete sebum to maintain moisture, condition

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Structure and Function—(cont.)Structure and Function—(cont.)

• Nails: epidermal appendage

– Some systemic diseases, infectious processes can affect nail growth rate, thickness.

• Sweat glands

– Function: thermoregulation

• Eccrine glands: cover most of body; most numerous in palms, soles

• Open directly onto skin

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Structure and Function—(cont.)Structure and Function—(cont.)

• Sweat glands—(cont.)

– Function: thermoregulation—(cont.)

• Apocrine glands: located in axillae, genital areas

• Open into hair follicles; activate at puberty

• Milky sweat + bacterial flora = musky odor

• Sebaceous glands: located throughout body, except palms, soles

• Secrete sebum: moisture retention, friction protection

• Inflammation of glands may result in acne.

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Structure and Function Overview—(cont.)Structure and Function Overview—(cont.)

Figure 11.1

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Lifespan Considerations: Older AdultsLifespan Considerations: Older Adults

• Effects of aging on integument

– Thinner skin: loses elastin, collagen, subcutaneous fat

– Decreased resilience; sagging/wrinkling; increased visibility; fragile superficial vascular structures

– Decreased melatonin; hair follicle atrophy

– Nail growth slows

• Nails thin, exhibit increased brittleness

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Cultural ConsiderationsCultural Considerations

• Cultural variations

– Becoming familiar with cultural variations facilitates

• Communication; accurate assessment

• Necessary patient education

• African Americans

– Keloid formation; Traction alopecia; pseudofolliculitis; folliculitis barbae; perineal follicularis

– Increased melasma in pregnancy; Mongolian spots

– Skin is commonly dry ashy dermatitis.

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• Asian

– Southeast Asian men: less body, facial hair

– Common

• Tattoos, body piercings, other skin adornments

– Rarely found outside Asian populations

• Hori nevus; nevus of Ota

• Henna tattoos: Arabic, Indian females

• Common Arabic lesions: Mongolian spots; café au lait spots; congenital nevi

Cultural Considerations—Cultural Considerations—(cont.)(cont.)

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Urgent AssessmentUrgent Assessment

• Prompt evaluation; interventions/repair

– Acute dehydration, cyanosis, or acute lacerations (impaired skin integrity)

– Not usually emergent

• Suspicious lesions: concern about cancer

• Rash + fever: infectious process?

• Acute trauma, burns

– May require immediate attention

– Large area: urgent; potentially life-threatening

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• Assessment of risk factors

– General health; personal history

– Medications; risk factors

• Risk assessment and health promotion

– Skin self-assessment

• SSE procedure

• Patient education regarding

• Limiting excessive UV radiation

• Characteristics of normal/problematic moles

Subjective Data CollectionSubjective Data Collection

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Common Symptoms Common Symptoms

• Common integumentary symptoms

– Pruritus (itching)

– Rash

– Single lesion/wound

• Lifespan considerations: older adult

• Cultural considerations

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QuestionQuestion

• Is 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.

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AnswerAnswer

• 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 DataObjective Data

• Common and specialty or advanced techniques

– Complete skin assessment: head-to-toe

– More common: affected body area only

– Characteristics: color; texture; moisture; turgor; temperature

– Assess/describe alterations during focused assessment.

• Objective data collection

– Equipment needed; preparation

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Comprehensive Skin AssessmentComprehensive Skin Assessment

• Inspection

– Reposition bedbound patient to visualize all body surfaces

• Priority areas: bony prominences; skin folds

– Categorize lesions

• Primary (arise from normal skin)

• Maculae; papules; nodules; tumors; polyps; wheals; blisters; cysts; pustules; abscesses

• Secondary (follow primary lesions)

• Scar tissue; crusts (from dried burns)

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Comprehensive Skin Assessment—(cont.)Comprehensive Skin Assessment—(cont.)

• Palpation

– Assess

• Temperature

• Turgor

– Hair

• Lifespan considerations: older adults

– Common skin assessment findings

– Increased risk for abnormal: ecchymoses/purpuric lesions; skin cancer

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Critical ThinkingCritical Thinking

• Integumentary alterations often reflect status of other systems.

• Laboratory and diagnostic testing

– Scraping: microscopic examination

– Culture and sensitivity: Identify infective lesions or exudate.

– Wood light: scalp infections

– Biopsy: diseases which manifest lesion changes

• Color, size, shape

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Diagnostic ReasoningDiagnostic Reasoning

• Nursing diagnosis, outcomes, and interventions

– Critical 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 patient’s status (partial list).

• Assess skin, risk for skin breakdown.

– Evaluate: efficacy of interventions to achieve outcomes.

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QuestionQuestion

• You 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 nurse’s best answer?

A. Twice daily

B. Daily

C. Every 2 to 3 days

D. Weekly

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AnswerAnswer

• C. Every 2 to 3 days

• Rationale: Elderly patients need to bathe less often, usually every 2 to 3 days.


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