Chapter 11— Skin, Hair, and Nails - PowerPoint Presentation

Chapter 11— Skin, Hair, and Nails Assessment

Integumentary System Includes: skin, hair, nails, sweat glands Provides vital information about patient’s health status Offers systemic data regarding Thermoregulatory; endocrine; respiratory Cardiovascular; gastrointestinal; neurological Urinary; immune Reflects status Hydration; nutrition; emotional

Structure and Function #1 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 #2 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

Structure and Function #3 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

Structure and Function #4 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

Structure and Function #5 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

Structure and Function #6 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 #7

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 turgor Decreased melatonin; hair follicle atrophy Nail growth slows Nails thin, exhibit increased brittleness

Cultural Considerations #1 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.

Cultural Considerations #2 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 Cupping, coining, ‘therapeutic burning’

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

Subjective Data Collection Assessment of risk factors General health; personal history Medications; risk factors Risk assessment and health promotion Skin self-assessment Self skin–examination (SSE) Patient education regarding Limiting excessive UV radiation Characteristics of normal/problematic moles

Common Symptoms Common integumentary symptoms Pruritus (itching) Rash Single lesion/wound Lifespan considerations : older adult Cultural considerations

Question #1 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 to Question # 1 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 #1 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 #2 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 #2 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

Answer to Question # 2 C. Every 2 to 3 days Rationale: Elderly patients need to bathe less often, usually every 2 to 3 days.