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Chapter 11—Skin, Hair, and Nails Assessment

Copyright © 2015 Wolters Kluwer • All Rights Reserved

Integumentary 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


Structure 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


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



• 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



• 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



• 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



• 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.


Structure and Function Overview—(cont.)

Figure 11.1


Lifespan 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


Cultural 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.


• 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.)


Urgent 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


• 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


Common Symptoms

• Common integumentary symptoms– Pruritus (itching)– Rash– Single lesion/wound

• Lifespan considerations: older adult• Cultural considerations


Question

• 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.


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.


Objective 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


Comprehensive 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)


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


Critical 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


Diagnostic 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.


Question

• 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 dailyB. DailyC. Every 2 to 3 daysD. Weekly


Answer

• C. Every 2 to 3 days• Rationale: Elderly patients need to bathe less often,

usually every 2 to 3 days.

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