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Skin, Hair, and Nails. By InnaKorda, MD, Institute of Nursing, TSMU. Anatomy. Epidermis Stratum germinativum (basal cell layer) Mitosis occurs here Contains melanocytes, producing melanin Stratum corneum - PowerPoint PPT Presentation
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Skin, Hair, and Nails
By InnaKorda, MD, By InnaKorda, MD,
Institute of Nursing, TSMUInstitute of Nursing, TSMU
Anatomy
Epidermis Stratum germinativum (basal cell layer)
Mitosis occurs here Contains melanocytes,
producing melanin Stratum corneum
As cells rise, they die and their cytoplasm is converted to keratin, which has a rough, horny texture
This layer undergoes constant shedding
Dermis Mostly connective tissue, primarily
collagen Provides support and nourishment of
epidermis Blood vessels, nerves, muscle, sweat
glands, sebaceous glands, hair follicles Subcutaneous Layer (Hypodermis)
Consists mostly of fat Provides protection, insulation, and
caloric source
Anatomy Hair
Composed of keratin Can be fine (vellus hair) or darker and thicker (terminal hair)
Sebaceous glands Produce sebum through hair follicles, which make skin oily. Prevent
water loss. Sweat glands
Eccrine – smaller, coiled tubules which open to skin surface Apocrine – larger, open to hair follicles. Located mainly in axillae
and genital area. Produce thick secretions, which react with bacteria on skin surface to produce body odor
Nails Composed of keratin Clear with highly vascular bed of epithelial cells underneath
Pulse oxymetry!
Used to measures what?
Developmental Considerations Infants
Lanugo – fine soft hair present at birth
Skin is thinner, less fat – more prone to dehydration and hypothermia
Pregnancy Linea nigra – line down midline of
abdomen Chloasma – face of pregnancy Striae gravidarum – stretch
marks Aging
Stratum corneum thins, loss of collagen, elastin, and fat, decrease of sebaceous and sweat glands,
More prone to dehydration and hypothermia
Chloasma
History
History of skin disease What was it? How was it treated? Does it run in the family?
Significant familial predispositions – allergies, hay fever, psoriasis, eczema, acne
Any know allergies? Any tattoos or birthmarks?
Use of nonsterile equipment for tattoos increases risk of Hep C Change in pigmentation
Might suggest systemic illness (jaundice) Change in a mole Pruritus
Any dryness? Is it seasonal? Xerosis – dry Seborrhea - oily
History Excessive bruising
Consider abuse Frequent minor trauma may be sign of alcohol abuse
Rash or lesion Onset Location Spread Character or quality Duration Associative factors – pets, co-worker? Alleviating and aggravating factors – what have you tried to
do? Patient’s perception - what do you think it is?
Medications Prescription and over-the-counter
May indicate allergy to medication
History
Hair loss or growth Gradual or sudden? Hirsutism – unusual growth
Change in nails Exposure to hazards
May be environmental or occupational Bitten by bee, tick, mosquito? Exposure to plants or animals?
Self care What cosmetics, soaps, chemicals?
Possible allergies
Physical Examination - Color
General pigmentation – should be even throughout
Benign pigmented areas Freckles (macules) on
sun exposed skin Nevi (moles)
Junctional nevi – macular only
Compound nevi – macular and papular
Dysplastic - precancerous
Birthmarks
Vitiligo – absence of melanin in patchy areas
ABCDE of malignant melanoma
1. Asymmetry – one lesion that is not regularly round or oval
2. Border – irregular 3. Color – variations 4. Diameter – greater than 6mm5. Elevation
*****
Changes in Color in Light Skinned People Pallor
Pale, white color caused by decrease of blood flow (vasoconstriction) or decrease in hemoglobin
Shock, anemia Erythema
Redness due to increased blood flow (vasodilation) Fever, inflammatory process, emotions, CO poisoning
Cyanosis Bluish, purplish hue due to decreased perfusion of tissues Hypoxemia due to heart failure, shock, chronic bronchitis
Jaundice Yellow, orange hue due to jaundice (increased bilirubin in
blood) Due to liver problems such as hepatitis, cirrhosis
Color Changes in Darker Skinned People
Pallor Brown skinned people will be more yellow. Black skinned
people will be more gray Palpebral conjunctiva and nail beds should be observed
Erythema Cannot be observed If fever suspected, check skin for warmth. If edema, check skin
for tightness Cyanosis
Darker skinned people have normal bluish tone on lips Palms, but not clearly evident, other clinical signs should be
observed Jaundice
Hard and soft palate must be observed in addition to sclera of eyes
Dark urine also presentTable 12.2
Skin Assessment (cont.) Temperature
Check skin with dorsa of hands Hyperthyroidism may cause increase of temp
Moisture Diaphoresis may occur during fever or exercise Dehydration can be observed by dry mucous membranes in mouth
and cracked skin Mobility and Turgor
Mobility is ease of skin rising when pinched. Turgor is returning back to its place
Slow turgor can be indicative of dehydration. “Tenting” if severe dehydration.
Lesions A lesion is any traumatic or pathological change in skin Describe using ABCDE, also noting location and exudate Roll nodule gently between fingers to assess depth Ultraviolet light is used if fungal infection suspected (Wood’s light)*****
Skin Assessment - shapes
Annular Circular, beginning in center
and spreading to periphery (ringworm)
Polycyclic Annular lesions that grow
together Confluent
Lesions run together (hives) Discrete
Individual lesions that remain separate
Shapes
Grouped Clusters of lesions (contact
dermatitis) Gyrate
Twisted, coiled Target
Concentric rings of color Linear
Scratch like, stripe Zosteriform
Follow nerve route (shingles)
Primary vs. Secondary
Primary skin lesions Variations in color or texture that may be present at
birth, such as moles or birthmarks, or that may be acquired during a person's lifetime, such as those associated with infectious diseases (e.g. warts, acne, or psoriasis), allergic reactions (e.g. hives or contact dermatitis), or environmental agents (e.g. sunburn, pressure, or temperature extremes).
Secondary skin lesions Changes in the skin that result from primary skin
lesions, either as a natural progression or as a result of a person manipulating (e.g. scratching or picking at) a primary lesion.
Primary Skin Lesions
Macule color change and less
than 1 cm may be to darker or
lighter Freckles, flat nevi,
hypopigmentation, petechiae
Patch Color change and
greater than 1cm Mongolian spots,
vitiligo, chloasma
Primary Skin Lesions
Papule Elevated lesion less
than 1cm in diameter Due to elevation in
epidermis Ex: wart, elevated
nevus Plaque
Elevation greater than 1cm in diameter
Ex: psoriasis
Primary Skin Lesions
Nodule Elevated solid greater
than 1cm Extending deeper into
dermis Tumor
Greater than few cm in diameter
May be firm or soft
Primary Skin Lesions
Wheal Superficial, raised,
transient, and erythematous lesion
Ex. Mosquito bite, allergic reaction
Primary Skin Lesions
Cyst Encapsulated fluid
filled cavity in dermis or subcutaneous layer
Vesicle Elevated cavity
containing free fluid, clear
Less than 1cm diameter
Ex: herpes simplex, varicella zoster
Primary Skin Lesions
Bulla Larger than 1cm in
diameter Superficial in
epidermis, thin walled Ex: blisters, burns
Pustule Pus in cavity Ex: impetigo, acne
Secondary Skin Lesions
Crust Thick, dry exudate
after rupture or drying up of vesicle or pustule
Ex: Impetigo, scab following abrasion
Scale Dry or greasy flakes of
skin resulting from shedding of excess keratin cells
Ex: psoriasis, eczema, seborrheic dermatitis
Secondary Skin Lesions
Fissure Linear cracks
extending into dermis Ulcer
Deep depression extending into dermis
May bleed. Leave scar.
Excoriation Self inflicted abrasion
often from scratching
Secondary Skin Lesions
Lichenification Tightly packed papules
from prolonged intense scratching
Keloid Hypertrophic scar Cannot be removed
surgically More common in black
people
Skin Lesions associated with AIDS – Kaposi’s Sarcoma
Patch stage Early lesions are faint and
pink Advanced stage
Widely disseminated lesions involving skin, mucous membranes, and visceral organs
Violet colored tumors on nose and face
Epidemic stage Lesions develop into raised
papules of thickened plaques.
Oval in shape and vary in color from red to brown.
Hair and Scalp
Ringworm may develop in scalp of school age children
Abnormalities in amounts and location of hair can be attributed to hormonal problems Hirsutism – excess body hair
Observe for head or pubic lice, which are white ovals on hair shafts.
Dandruff is indicated by loose white flakes
Abnormal Conditions of Hair
Tinea capitis (scalp ringworm) Lesions fluoresce blue-green
under Wood’s light Highly contagious
Toxic alopecia Asymmetric balding that
accompanies severe illness or chemotherapy
Regrowth after discontinuation of toxin
Abnormal Conditions of Hair
Folliculitis Superficial infection of hair
follicles Multiple pustules
Furuncle and Abscess Red, swollen, hard, tender,
pus-filled lesion due to acute localized bacteria (staph)
Usually on back of neck, buttocks, wrists, or ankles
Furuncle is due to infected hair follicles
Abscess is due to traumatic introduction of bacteria into the skin. Deeper than furuncle
Nails
Good indicators of respiratory system health
Nail base Normal is about 160° Clubbing is the decrease
of the angle of nail base (<160°) that occurs as a result of respiratory insufficiency, common in COPD (emphysema, chronic bronchitis)
In early clubbing, the angle actually increased to about 180°
Spongy nails
Physiology of clubbing is not fully understood but respiratory insufficiency
seems to dilate peripheral arteries, causing a round fingernail shape
Nails
Consistency Variant thickness may suggest malnutrition Thickening of nails is sign of arterial insufficiency
Color Note any pigmentations – melanoma? Cyanotic nail beds – poor peripheral circulation
Capillary refill Indicator of peripheral circulation Measured by depressing the nail bed until it is white
and observing the time it takes for blood to return back to the nail
Normal time is less than 1-2 seconds and is indicated as “brisk.” “Sluggish” if greater than 2 seconds.
Developmental Considerations - Infants Mongolian spots
Hyperpigmentation of sacrum, buttocks, abdomen, thighs, shoulders, or arms
Very common in blacks, Asians, and Native Americans
Should not be confused with abuse
Café au lait “Coffee with milk” Patches of
hyperpigmentation Normal
Developmental Considerations - Infants
Acrocyanosis Bluish color around lips, hands, and feet Usually is due to coolness and disappears after warming
up Persistent cyanosis is indicative of congenital heart
disease Cutis marmorata
Mottling of trunk and extremities due to coolness If persistent, usually indicative of Down syndrome
Physiological jaundice Common yellowing of skin in newborns, which usually
appears after 4th day. UV light helps. Carotenemia
Yellowing of skin due to ingestion of large amts of carotene.
Developmental Considerations - Adolescents
Acne Most common skin problem Acne occurs when the hair
follicles, which are connected to sebaceous glands, become plugged with oil and dead skin cells.
Usually appear on face, shoulders, back, and chest
Can include papules, pustules, and nodules
Open comedones (blackheads)
Closed comedones (whiteheads)
Acne
Open comedones are a less severe form of acne
Vascular Lesions - Hemangiomas
Port-Wine Stain (Nevus Flammeus) Flat macular patch of
mature capillaries Benign
Strawberry Mark (Immature hemangioma) Raised bright red area Usually disappears by
age 7 Cavernous Hemangioma
Developmental Considerations - Pregnancy Striae Linea nigra Chloasma Vascular spiders
Developmental Considerations - Aging Senile lentigines
Liver spots – melanocyte clusters
Usually on hands and face
Seborrheic keratosis Raised, thick, crusted
“mole” Dry skin is common Acrochordons
Overgrowths of skin – normal
Frequently occur on back, eyelids, axillae
Developmental Considerations - Aging Decreased turgor, tenting of skin occurs Hair growth decreases, thins Fungal infections of toenails
Teaching Self-Exam
Pressure Ulcers
Stage I A reddened area on
the skin that, when pressed, is "non-blanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop.
Stage II The skin blisters or
forms an open sore. The area around the sore may be red and irritated.
Pressure Ulcers
Stage III The skin breakdown
now looks like a crater where there is damage to the tissue below the skin.
Stage IV The pressure ulcer
has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.
Braden Scale
Sensory Perception Activity Mobility Skin Moisture Friction and Shear Nutrition
1-4 with the exception of friction & shear subscale 1-3
Range 4-23 The lower the score
the higher the risk Eighteen or less:
high risk older adult
Question 1
A nurse is reviewing the health care records of clients scheduled to be seen at the health care clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder?
1. An elderly female2. An adolescent3. An outdoor construction worker4. A physical education teacher
Question 2
A clinic nurse notes that the physician has documented a diagnosis of herpes zoster in a client’s chart. On the basis of an understanding of the cause of this disorder, the nurse would determine that this definitive diagnosis was made following which diagnostic test?
1. Skin biopsy2. Wood’s light examination3. Culture of the lesion4. Patch test
Question 3
A nurse is assessing for the presence of cyanosis in a dark-skinned client. The nurse understands that which body are would provide the best assessment?
1. Back of hands
2. Earlobes
3. Palms of hands
4. Sacrum
Question 4
Which of the following clients would least likely be at risk for the development of skin breakdown?
1. A client who is unable to move about and is confined to bed
2. A client incontinent of urine and feces
3. A client with chronic nutritional deficiencies
4. A client with a lowered mental awareness
Question 5
A nurse provides home care instructions to a client diagnosed with impetigo. Which of the following would not be a component of the teaching plan? Continue with the antibiotics prescribed Wash the client’s dishes separately from those
of other household members It is not necessary to separate the client’s linin
and towels from those of other household members
Wash hands thoroughly and frequently throughout the day