nrs 103 skin, hair, and nails chapter 9
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DESCRIPTIONNRS 103 Skin, Hair, and Nails Chapter 9. Nancy Sanderson MSN, RN. Integumentary System. Skin and accessary structures (nails, hair sweat glands and sebaceous glands) form the integumentary system. The skin is elastic, self generating and covers the entire body. - PowerPoint PPT Presentation
NRS 103 Skin, Hair, and Nails Chapter 9
Nancy Sanderson MSN, RNNRS 103 Skin, Hair, and NailsChapter 9
Integumentary SystemSkin and accessary structures (nails, hair sweat glands and sebaceous glands) form the integumentary system. The skin is elastic, self generating and covers the entire body.Primary function is to protect the body from microbial and foreign substance invasion and protect internal body structures from physical trauma.The skin also helps to retain body fluids and electrolytes, provides sensory input about the environment, regulation to body temperatures, excretion of sweat, lactic acid, urea, expressing emotions, ie: blushing, production of vitamin D, repairs own wounds by cell replacement and could tell us of internal disorders by providing valuable clues. Skin LayersEpidermisOutermost layer. Barrier to external penetrationDermisUnderneath epidermis. Sensory organ for touch, pressure, & temperature. Contains nerves that innervate glands & blood vesselsSubcutaneousUnder dermis. Stores fat, generates heat, provides temperature regulation
Skin: why all the concern!May be an early sign warningJaundiceliver diseaseNailsanemia, trauma, hypoxia (per oxygenation) Hives/RashallergyRashinfection; auto-immune disease; insect bites (viruses/bacteria/parasites); tumor (benign/malignant); etc., etc., etc. Edemaheart or renal disease Tears, fissures, pressure ulcersinjury; immobility
4Health HistoryAny change in skin, hair, or nails? Increase in hair loss, thinning, or breakage?Nail splitting, thickening, discoloration, or separation from nail bed?Any rashes, sores, lumps, or itching?Any change in appearance of moles?Any lesions that slow or fail to heal?Assess risk factor for skin cancersSun exposure, blistering sunburns in childhood, family history, light skin, presence of atypical moles (dysplastic nevi), >50 common moles, or immunosuppresion
Health HistorySkin, hair, or nail complaint specificOLDCART of skin/hair/or nail complaintWhat did rash /lesion look like when first appearedPain, pruritus, burning?Previous or family hx of similar complaint? Resolution? Treatments?Change in skin products, detergents, foods, medications?What medications taking?Any environmental or occupational hazards?Change in nutrition status?Recent life changes (Losses, psychological/ physical stress) or travel out of US?Major health problems (severe cardiac, endocrine, respiratory, liver, hematologic, or other)?
Skin Exam BasicsGeneral inspection of entire body, followed by detailed regional examGood source of lighting needed, indirect natural daylight preferred.Consider using small magnifying glass to aid in examining lesionsUse clear flexible measure to assess sizeWear gloves for all skin examination!Protect patients modesty while exposing areas as fully as possibleRemove socks to examine feet and between toes
Inspection & Palpation of SkinColorTemperatureMoistureTexture
ColorEstablish baseline skin color by observing least pigmented skin surfaces (volar surface of forearm, palms/soles, abdomen, and buttocks)Vascular flush areas: cheeks, bridge of nose, neck, upper chest, flexor surfaces of extremities, genital areas (vascular disturbance, blushing, inc temp compare with less vascular areas)Pigment labile areas: face, back of hands, flexors or wrist, axillae, mammary areola, midline of abdomen, and genital area (acanthosis nigracans)
ColorPigmentation changesCyanosisJaundicePallorErythemaSkin color consistent with genetic background, in dark skin, color may be ashen-gray in mucous membranes
CyanosisA dusky blue color, may be visible in nail beds, lips, earlobes, & oral mucosaIn dark skinned- close inspection of nail beds, lips, palpebral conjunctiva, palms, and soles
A yellow or green hueOften first visible in sclera, then mucous membranes, then skinIn dark skinned- May normally be slightly yellow. View posterior portion of hard palate for yellowish cast. Yellowish/green color in sclera, palms of hands, and soles of feet,Pallor & ErythemaPallorDecreased color/red tone in skin. Skin paleMost evident in face, palpebral conjunctiva, mouth, and nail bedsIn dark skinned: Brown skin- yellowish brown tinge; Black skin- ashen gray. Absence of underlying red tones in skin. ErythemaIntense redness of skinIn dark skinned: Difficult to see. Usually associated with increased temperature so palpation should be used to assess for inflammatory condition
TemperatureTemperaturePalpate with dorsal aspect of hand on both sides of body for comparison of patients skin temperatureNormal: Warm depending on environmentAbnormal:Increased: burn, localized infection, feverDecreased: Circulatory problems, shock
Moisture & TextureMoistureNormal: Dry influenced by environmental/body temp and muscular activityAbnormal: Too moist vs Too dry (maceration)Dryer in winter (decreased humidity) & with ageMay indicate dehydration or thyroid disease TextureNormal: Smooth, firm, soft. Thickness varies in different areasAbnormal: Loose, wrinkles, rough, thickened, thin, oily, flaking, scaling, indurated (hardened)
Signs and Symptoms of DehydrationAltered mental statusLethargyLight headednessSyncopeDecreased skin turgorDry mucus membranesOrthostatic hypotensionModerate oliguria or anuriaResting hypotension
**Aging- decreased body water from 60-40% because increased body fat and increased lean body mass. Impaired water conservation & sodium imbalance**
LesionsLesionsTraumatic or pathological changes in previously normal structuresNote:ColorLocationSize in cmDischarge (amount, color, odor)Characteristics/ClassificationShape and configurationNo lesions noted
17Lesions, variations in skin color and nail beds The text book in chapter 9 has very good tables, pictures and descriptions of each condition, characteristics and abnormalities for various integumentary disorders. Please review and familiarize yourself with the definitions of lesions, nail beds and skin problems.
Basal Cell CarcinomaSquamous Cell CarcinomaMalignant MelanomaIrregular BordersDiameter of a malignant skin lesion is usually greater than 6 mm.Melanoma is a variety of colors.
Patient EducationMonthly inspect skin & scalp noting moles, blemishes and birthmarksContact health care provider if skin lesions begins to bleed, ooze, or feel differentAAsymmetryBBorders irregularCColor variationsDDiameter >6mmEElevationfrom flat to raisedFFeeling itching, tingling, or stinging
20Patient EducationPreventionWear wide brimmed hatApply broad-spectrum sunscreen (UVA & UVB) with SPF of 15 or greaterAvoid tanning under the direct sun at midday (10am-4pm)Do not use indoor sunlamps, tanning beds, or tanning pillsCertain medications such as oral contraceptives, antibiotics, antiinflammatories, antihypertensives, or immunosuppressives may make more sensitive to the sun
Braden Skin Scale cont.Scores range from 6-23Lower score means increased risk of skin breakdownMost facilities use # 18 as a cut off for skin precautionsAssess every shiftFrequent turningSpecial mattressGood Nutrition
Braden Pressure Ulcer Risk ScoreSensory PerceptionCompletely limited (1),very limited (2), slightly limited (3), no impairments (4)MoistureCompletely moist (1),very moist (2), occasionally moist (3), rarely moist (4)ActivityBedfast (1), Chairfast (2), Walks occasionally (3), walks frequently (4)MobilityCompletely immobile (1),very limited (2), slightly limited (3), no limitations (4)NutritionVery poor (1), probably inadequate (2),adequate (3), excellent (4)Friction & ShearProblem (1), potential problem (2), no apparent problem (3)23Pressure UlcersAKABedsoreDecubitus ulcerDefinitionLocalized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or frictionPressure leads to collapse of blood vessels in area, leading to ischemia
24Pressure UlcersAreas most susceptible: Occipital skull, pinna or ears, sacrum, ischial tuberosity, tronchanter area of hip, ankles, and heelsContributing factors: Impaired mobility/immobility, incontinence, poor nutritional status, altered LOC
Pressure Ulcer Stages
(Suspected) Deep Tissue InjuryStage IStage IIStage IIIStage IVUnstageable26Stage IStage iiStage iiiStage ivStage VOn pg. 122 & 123 are very good pictures and description of each stage of a pressure ulcer please review and familiarize yourself with each.
Staging of Pressure UlcersInspection/Palpation - NailContourAngle approx 160 degrees. > 180 is abnormal (Clubbing-sign of hypoxia)ColorNail translucent, nail bed pinkCapillary refill