Structure and Function of Skin The skin is the largest organ of the body The skin is a physical barrier that protects the underlying tissues and structures from microorganisms physical trauma ultraviolet radiation and dehydration ID: 998365
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1. Chapter 14 Assessing Skin, Hair, and Nails
2. Structure and Function of SkinThe skin is the largest organ of the body.The skin is a physical barrier that protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, and dehydration.Vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.
3. Skin, Hair, and NailsSkin: epidermis, dermis, sebaceous glands, sweat glands, subcutaneous layersHair: vellus, terminalNails: nail body, lunula
4. QuestionIs the following statement true or false?Sebum has some fungicidal and bactericidal effects.
5. AnswerTrue.Sebum has some fungicidal and bactericidal effects.
6. QuestionIs the following statement true or false?Asians and Native Americans have strong body odor.
7. AnswerFalse.Asians and Native Americans have mild to no body odor because of decreased sweat production. Caucasians and African Americans tend to have a strong body odor.
8. Skin CancerMost common of cancersThree types: melanoma, basal cell carcinoma, squamous cell carcinomaAsians are less susceptible
9. Risk Factors of Skin CancerSun exposureNonsolar sources of ultraviolet radiationMedical therapiesFamily history and genetic susceptibilityMolesPigmentation irregularitiesFair skin that burns and freckles easily; light hairAgeActinic keratosis
10. Risk Factors of Skin Cancer (cont.)Male genderChemical exposureHuman papillomavirusXeroderma pigmentosumLong-term skin inflammation or injuryAlcohol intake; smokingInadequate niacin in dietBowen disease (scaly or thickened patch) (SCC)Depressed immune system
11. Risk Reduction in Skin CancerReduce skin exposure.Always use sunscreen when sun exposure is anticipated.Wear long-sleeve shirts and wide-brimmed hats.Avoid sunburns.Wear sunglasses that wrap around.Understand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on developing cancers.Have annual skin cancer screenings.
12. Risk Reduction in Skin Cancer (cont.)Ensure that diet is adequate in vitamin B3 (niacin).Examine the skin for suspected lesions using the ABCDE mnemonic to assess suspicious lesions:AsymmetryBorderColorDiameterEvolution (changes over time)
13. QuestionWhich skin disorder may be caused by exposure to the sun?A. AcneB. Cancer C. VitiligoD. Warts
14. AnswerB. Cancer.Skin cancer may be caused by exposure to the sun. Acne, vitiligo, and warts are not caused by sun exposure.
15. Cultural Variations in Skin CancerAsians are less susceptible to skin cancer African Americans, Asians, and Hispanics are susceptible to melanomaAsian Americans and African Americans tend to present with more advanced disease at diagnosis
16. Risk Factors for Methicillin-Resistant Staphylococcus aureus Assess for hospital-acquired MRSA risk factors:Having an invasive medical deviceResiding in a long-term care facilityPresence of an MRSA-positive person in the facility
17. Risk Factors for Methicillin-Resistant Staphylococcus aureus (cont.)Assess for community-acquired MRSA risk factors:Participating in contact sportsSharing personal items such as towels or razorsSuppression of immune system function (e.g., HIV, cancer, or chemotherapy)Residing in unsanitary or crowded living conditions (e.g., dormitories or military barracks)
18. Risk Factors for Methicillin-Resistant Staphylococcus aureus (cont.)Working in the health care industryReceiving antibiotics within the past 3 to 6 monthsYoung or advanced ageMen having sex with menHemodialysis
19. Measures to Reduce Risk Factors for Methicillin-Resistant Staphylococcus aureusKeep wounds covered.Do not share personal items. Avoid unsanitary or unsafe nail care practices.If treatment has been started, do not stop until recovery is complete.Use universal precautions when touching others to avoid contact with contaminated body fluids. Wash your hands.Clean sports equipment between uses to avoid spread of infection.Wash clothes, sheets, towels, razors, and other personal items before and after use.Clean hands often.
20. Nursing History: Present Health ConcernBody odor problemsSkin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation)Changes in lesion appearanceFeeling changes (pain, pressure, itch, tingling)Hair loss or changesNail changes
21. Nursing History (cont.)Personal health historyFamily historyLifestyle and health practicesExposure to sun or chemicalsDaily care of skin, hair, and nailsUsual diet and exercise patterns
22. Client PreparationAsk the client to remove all clothing and jewelry.Have the client sit comfortably.Ensure privacy.Maintain comfortable room temperature.
23. Equipment for Skin, Hair, and Nail AssessmentGlovesExamination light and penlightMirror for client’s self-examination of skinMagnifying glassCentimeter rulerWood lightExamination gown or drapeAssessment Tool 14-1, Braden Scale For Predicting Pressure Sore RiskAssessment Tool 14-2, PUSH Tool to Measure Pressure Ulcer Healing
24. Skin Assessment: InspectionNote any distinctive odorGeneralized color variationsSkin breakdownPrimary, secondary, or vascular lesions
25. Skin Assessment: PalpationLesionsTextureTemperature and moistureThickness of skinMobility and turgorEdema
26. Pressure Ulcer Risk FactorsPerceptionMobilityMoistureNutritionFriction or shear against surfacesTissue tolerance decreased
27. Pressure Ulcer Risk ReductionInspect the skin at least daily and more often if at greater risk using risk assessment tool (such as Braden Scale or PUSH tool) and keep flow chart to document.Bathe with mild soap or other agent; limit friction; use warm, not hot, water; set bath schedule that is individualized.For dry skin: use moisturizers; avoid low humidity and cold air.Avoid vigorous massage.
28. Pressure Ulcer Risk Reduction (cont.)Use careful positioning, turning, and transferring techniques to avoid shear and friction or prolonged pressure on any point.Refer nutritional supplementation needs to primary care provider or dietitian, especially if protein deficient.Refer incontinence condition to primary care provider.Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products.
29. Scalp and HairInspection and palpationGeneral color and condition, cleanliness, dryness or oiliness, parasites, and lesionsAmount and distribution of scalp, body, axillae, and pubic hair
30. Nail AssessmentNailsInspection: Nail grooming and cleanliness, nail color and markings, shape of nails Palpation: Assess texture and consistency, capillary refill
31. Nails Risk FactorsNails in moist environment, especially walking in damp public locales or continuously wearing closed shoes; excessive perspirationNail injury, trauma, or irritation Repeated irritation (especially water, detergents) Immune system disorders such as diabetes mellitus and AIDS or on immunosuppressive medicationsSkin conditions such as psoriasis or lichenSome trades or professions Contagion from one digit to another or one person to anotherPossibly family predisposition
32. Nails Risk Reduction TipsWear leather shoes except for sports.Avoid wearing closed shoes all the time.Wear socks that wick away moisture.Avoid going barefoot in damp public areas.Avoid too much perspiration or water (wear gloves for hands).Avoid trauma to nails.Avoid unsanitary or unsafe nail care practices.If treatment is started, do not stop until recovery is complete.
33. Physical AssessmentCapillary refill assessment procedureHair color and textureIndividuals of African American descent often have very dry scalps and dry, fragile hair.
34. Self-Assessment of Skin, Hair, NailsRefer to Box 14-1, Self-Assessment: How to Examine Your Own Skin
35. Normal and Abnormal FindingsShare outcomes of skin, hair, and nails assessment with peers
36. Pressure Ulcer StagesStage IStage IIStage IIIStage IVUnstagable
37. Primary Skin LesionsMacule and patchPapule and plaqueNodule and tumorVesicle and bullaWhealPustuleCyst
38. Secondary Skin LesionsErosionUlcerScarFissure
39. Vascular Skin LesionsPetechiaEcchymosisHematomaCherry angiomaSpider angiomaTelangiectasis
40. Common Nail DisordersLongitudinal ridgingHalf-and-half nailsPittingKoilonychiaYellow nail syndromeParonychia
41. Common Changes in Aging Skin, Hair, and NailsSkinPaleSkin lesionsDryLoses turgorHair: ThinnerNails: Thickened, yellow, brittle
42. Validating and Documenting FindingsHealth promotion diagnosesRisk diagnosesActual diagnosesCollaborative problemsMedical problems