NANCY SANDERSON MSN, RN

NRS 103 Skin, Hair, and Nails

Chapter 9

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.

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 Layers

Epidermis Outermost layer.

Barrier to external penetration

Dermis Underneath epidermis.

Sensory organ for touch, pressure, & temperature. Contains nerves that innervate glands & blood vessels

Subcutaneous Under dermis. Stores

fat, generates heat, provides temperature regulation

Skin: why all the concern!

May be an early sign warning Jaundice—liver disease Nails—anemia, trauma, hypoxia (per oxygenation) Hives/Rash—allergy Rash—infection; auto-immune disease; insect bites

(viruses/bacteria/parasites); tumor (benign/malignant); etc., etc., etc.

Edema—heart or renal disease Tears, fissures, pressure ulcers—injury; immobility

Health History

Any 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 cancers

Sun exposure, blistering sunburns in childhood, family history, light skin, presence of atypical moles (dysplastic nevi), >50 common moles, or immunosuppresion

Health History

Skin, hair, or nail complaint specific OLDCART of skin/hair/or nail complaint What did rash /lesion look like when first appeared Pain, 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 Basics

General inspection of entire body, followed

by detailed regional exam Good source of lighting needed, indirect

natural daylight preferred. Consider using small magnifying glass to

aid in examining lesions Use clear flexible measure to assess size Wear gloves for all skin examination! Protect patient’s modesty while exposing

areas as fully as possible Remove socks to examine feet and

between toes

Inspection & Palpation of Skin

ColorTemperature

MoistureTexture

Vascularity/bruising

EdemaLesions

Color

Establish 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)

Color

Pigmentation changes Cyanosis Jaundice Pallor ErythemaSkin color consistent with genetic background, in dark skin, color may be ashen-gray in mucous membranes

Cyanosis

A dusky blue color, may be visible in nail beds, lips, earlobes, & oral mucosa

In dark skinned- close inspection of nail beds, lips, palpebral conjunctiva, palms, and soles

JaundiceA 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 & Erythema

Pallor Decreased color/red tone in skin. Skin pale Most evident in face, palpebral conjunctiva,

mouth, and nail beds In dark skinned: Brown skin- yellowish

brown tinge; Black skin- ashen gray. Absence of underlying red tones in skin.

Erythema Intense redness of skin In dark skinned: Difficult to see. Usually

associated with increased temperature so palpation should be used to assess for inflammatory condition

Temperature

Temperature Palpate with dorsal aspect of hand on both sides

of body for comparison of patient’s skin temperature

Normal: Warm depending on environment

Abnormal: Increased: burn, localized infection,

fever Decreased: Circulatory problems,

shock

Moisture & Texture

Moisture Normal: Dry

influenced by environmental/body temp and muscular activity

Abnormal: Too moist vs Too dry (maceration) Dryer in winter (decreased humidity) & with

age May indicate dehydration or thyroid disease

Texture Normal: Smooth, firm, soft. Thickness varies in

different areas Abnormal: Loose, wrinkles, rough, thickened,

thin, oily, flaking, scaling, indurated (hardened)

Signs and Symptoms of Dehydration

Altered mental status Lethargy Light headedness Syncope Decreased skin turgor Dry mucus membranes Orthostatic hypotension Moderate oliguria or anuria Resting hypotension

**Aging- decreased body water from 60-40% because increased body fat and increased lean body mass. Impaired water conservation & sodium imbalance**

Lesions

Lesions Traumatic or pathological changes in previously

normal structures Note:

Color Location Size in cm Discharge (amount, color, odor) Characteristics/Classification Shape and configurationNo lesions noted

Lesions, 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.

Cancers

Basal Cell CarcinomaSquamous Cell

CarcinomaMalignant Melanoma

•Irregular Borders•Diameter of a malignant skin lesion is usually greater than 6 mm.•Melanoma is a variety of colors.

Patient Education

Monthly inspect skin & scalp noting moles, blemishes and birthmarks

Contact health care provider if skin lesions begins to bleed, ooze, or feel different

A Asymmetry

B Borders irregular

C Color variations

D Diameter >6mm

E Elevation—from flat to

raised F

Feeling –itching, tingling, or stinging

Patient Education

Prevention Wear wide brimmed hat Apply broad-spectrum sunscreen (UVA & UVB)

with SPF of 15 or greater Avoid tanning under the direct sun at midday (10am-4pm) Do not use indoor sunlamps, tanning beds, or

tanning pills Certain medications such as oral contraceptives,

antibiotics, antiinflammatories, antihypertensives, or immunosuppressives may make more sensitive to the sun

Braden Skin Scale cont.

Scores range from 6-23 Lower score means increased risk of skin

breakdown Most facilities use # 18 as a cut off for skin

precautions Assess every shift Frequent turning Special mattress Good Nutrition

Braden Pressure Ulcer Risk Score

Sensory Perception Completely limited (1),very limited (2), slightly limited (3), no

impairments (4) Moisture

Completely moist (1),very moist (2), occasionally moist (3), rarely moist (4)

Activity Bedfast (1), Chairfast (2), Walks occasionally (3), walks

frequently (4) Mobility

Completely immobile (1),very limited (2), slightly limited (3), no limitations (4)

Nutrition Very poor (1), probably inadequate (2),adequate (3), excellent

(4) Friction & Shear

Problem (1), potential problem (2), no apparent problem (3)

Pressure Ulcers

AKA Bedsore Decubitus ulcer

Definition Localized 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 friction Pressure leads to collapse of blood vessels in area,

leading to ischemia

Pressure Ulcers

Areas most susceptible: Occipital skull, pinna or

ears, sacrum, ischial tuberosity, tronchanter area of hip, ankles, and heels

Contributing factors: Impaired

mobility/immobility, incontinence, poor nutritional status, altered LOC

Pressure Ulcer Stages

(Suspected) Deep Tissue Injury

Stage IStage IIStage IIIStage IVUnstageable

STAGE ISTAGE IISTAGE IIISTAGE IVSTAGE V

ON 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 Ulcers

Inspection/Palpation - Nail Contour

Angle approx 160 degrees. > 180 is abnormal (Clubbing-sign of hypoxia)

Color Nail translucent, nail bed pink Capillary refill <2seconds

Consistency Smooth, regular, thickness

uniform. Nail adherent to nail bed.

Nail changes in Elderly Grow more slowly, lose luster, with longitudinal ridging.

Inspection/Palpation - Hair

Quantity Hair loss

Male pattern baldness, drugs, radiation, hormone levels, stress

Increased hair growth Hirsutism

Lesions Separate hair and assess for lesions or pest

inhabitants No lesions or lice noted

Hair changes in elderly Grey Axilla & pubic hair decreases due to low

testosterone Women with bristly facial hair due to

unopposed testosterone (low estrogen)

Summary

Early signsKnow your terminology How to best assessPrevention, Prevention, Prevention