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Skin, Hair, and Nails DSN Kevin Dobi, MS, APRN

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1 Skin, Hair, and Nails DSN Kevin Dobi, MS, APRN
Chapter 9 Skin, Hair, and Nails DSN Kevin Dobi, MS, APRN Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

2 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Tissue Integrity Concept represents structural intactness and physiologic function of tissues and conditions that affect integrity. Tissues referred to: Skin, hair, and nails. Interrelated concepts: Perfusion Oxygenation Motion Tactile sensory perception Elimination Nutrition Pain Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

3 Anatomy and Physiology
Integumentary system: Skin and accessory structures Hair Nails Sweat glands Sebaceous glands Skin considered a body organ, an elastic, self-regenerating cover for entire body Primary functions Protects the body from invasion. Protects internal body structures from physical trauma. Helps retain body fluids and electrolytes. Produces vitamin D. Helps regulate body temperature. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

4 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

5 Anatomy and Physiology: Layers of Skin
Composed of three functionally related layers: Epidermis Dermis Subcutaneous layer (hypodermis) Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

6 Anatomy and Physiology: Epidermis
Thin, outermost layer of skin composed of stratified squamous epithelium: Is avascular. Stratum germinativum is deepest layer: Lies adjacent to rich supply of blood of dermis. Site of active cell generation. As new cells are produced, they push older cells toward skin surface where they begin to die and undergo process keratinization, causing cells to become flat, hard, and waterproof. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

7 Anatomy and Physiology: Outermost Aspect Epidermis
Stratum corneum is outermost aspect of epidermis: Composed of 30 layers of dead, flattened, keratinized cells. Exposed layer serves as protective barrier and regulates water loss. Dead cells are continuously sloughed off and replaced by new cells moving from the underlying epidermal layers. Process takes about 30 days. Contains melanocytes that secrete melanin: Provides pigment. Shields from ultraviolet radiation. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

8 Anatomy and Physiology: Dermis
Dermis made up of highly vascular connective tissue. Thickness varies from 1 mm to 4 mm. Blood vessels dilate and constrict in response to heat and cold, and to internal stimuli of anxiety or hemorrhage, resulting in regulation of body temperature and blood pressure. Dermal blood nourishes epidermis. Also contains sensory nerve fibers for touch, pain, and temperature. Arrangement of connective tissue enables dermis to stretch and contract with body movement. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

9 Anatomy and Physiology: Subcutaneous Layer
Subcutaneous tissue (hypodermis) is not actually skin tissue, but a support structure for dermis and epidermis. Acts as anchor for upper layers. Composed primarily of loose connective tissue interspersed with subcutaneous fat. Fatty cells help retain heat and provide protective cushion, and calories. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

10 Anatomy and Physiology: Appendages
Hair, nails, and glands (eccrine sweat glands, apocrine sweat glands, and sebaceous glands) are considered appendages. Structures formed at junction of epidermis and dermis. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

11 Anatomy and Physiology: Hair
Hair formed from epidermal cells in the dermis Each hair consists of: A root A shaft A follicle (the root and it’s covering) Base of follicle contains: Papilla A capillary loop Melanocytes provide color. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

12 Anatomy and Physiology: Nails
Nails are epidermal cells converted to hard plates of keratin: Composed of a free edge Nail plate Nail root (site of nail growth) The white crescent-shaped area at base, the lunula, represents new nail growth. Paronychium is tissue adjacent to nail. Cuticle is epidermal tissue (stratum corneum) growing on nail plate at nail base. Tissue directly under nail is highly vascular and provides clues to oxygenation status and blood perfusion. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

13 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

14 Anatomy and Physiology: Eccrine Sweat Glands
Eccrine sweat glands regulate body temperature by water secretion through skin’s surface. Most numerous and widespread sweat glands on body. Distributed almost everywhere throughout skin’s surface: Greatest numbers on palms of hands, soles of feet, and forehead. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

15 Anatomy and Physiology: Apocrine Sweat Glands
Apocrine sweat glands are much larger and deeper than eccrine glands. Found only in axillae, nipples, areolae, anogenital area, eyelids, and external ears. Secrete odorless fluid containing protein, carbohydrates, and other substances in response to emotional stimuli. Body odor is produced by decomposition of apocrine sweat. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

16 Anatomy and Physiology: Sebaceous Glands
Sebaceous glands secrete lipid-rich substance, sebum, which keeps skin and hair from drying out. Greatest distribution found on face and scalp; although found in all areas of body except palms and soles Sebum secretion, stimulated by sex hormone activity, varies throughout lifespan. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

17 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Present Health Status Do you have any chronic illnesses? Do you take any medications? What do you take, and how often? Have you noticed changes in the way your skin and hair look or feel? Any changes in sensation of your skin? What kind of work do you do? To your knowledge, are you exposed to any chemicals at home or work? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

18 Past Health History and Family History
Have you ever had problems with your skin such as skin disease, infections involving skin or nails, or trauma involving skin? Has anyone in your family ever had skin-related problems such as skin cancer or autoimmune-related disorders such as systemic lupus erythematosus? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

19 Problem-Based History
Pruritus is most commonly reported symptom of skin disease. Other common problems related to skin: Rashes Pain/discomfort Lesions Wounds Changes in skin color or texture, hair, or nails Complete symptom analysis: Onset Location Duration Characteristics Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

20 Problem-Based History: Pruritus
When did itching first start? Did it start suddenly or over time? Where did it start? Has it spread? Does anything make itching worse? Does anything relieve it? What have you done to treat it yourself? What were the circumstances when you first noticed itching? Taking any medications? Contact with possible allergens such as animals, foods, drugs, plants? Do you have dry or sensitive skin? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

21 Problem-Based History: Rash
When did rash start? Describe what it looked like initially: flat? raised? How long has rash been present? Does it itch or burn? What makes it better? Worse? What have you done to treat it? Have you noticed other associated symptoms such as joint pains, fatigue, or fever? Do you have any known allergies? Does anyone else in your family have a similar rash? Have you been exposed to others with a similar rash? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

22 Problem-Based History: Pain/Discomfort of Skin
Describe pain or discomfort: When did pain start? Where is it located? Does pain stay on skin surface, or go deep inside? Describe pain or discomfort—sharp, dull, achy, burning, itching: How bad on a scale of 0 to 10? Is pain constant, or does it come and go? What triggers pain? What makes it worse? Better? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

23 Problem-Based History: Lesions or Changes in Moles
Describe lesion you are concerned about. Where is lesion? When did you first notice it? Do you have any symptoms associated with lesion such as pain, discomfort, pruritus, or drainage? Describe changes you have noticed in mole: Color Shape Texture Tenderness Bleeding Itching Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

24 Problem-Based History: Change in Skin Color
Has there been any generalized change in your skin color? Yellowish tone? Paleness? Have there been any localized changes in your skin color? Redness? Discoloration of one or both feet? Areas of bruises or patches? Vitiligo is loss of pigmentation in skin. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

25 Problem-Based History: Skin Texture
In what way has the texture of your skin changed? Thinning Fragile Excessive dryness Do you have excessively dry (xerosis) or oily (seborrhea) skin? Seasonal, intermittent, or continuous? What do you do to treat it? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

26 Problem-Based History: Wounds
Where is the wound located? What caused the wound? How long have you had it? Do you have associated symptoms such as pain or drainage? What have you done to treat the wound? Do you typically have problems with wound healing? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

27 Problem-Based History: Hair
What changes or problems with your hair are you experiencing? When did you notice the changes? Did the changes occur suddenly? Can you think of any contributory factors? Have you recently experienced stress? Fever? Other illness? What kinds of hair products were used on your hair recently? Have you changed diet in the last few months? Have you noticed any changes in distribution of hair growth on your arms or legs? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

28 Problem-Based History: Nails
What kind of problem or changes do you have with your nails? When did you first notice changes? Have you been exposed to chemicals at home or work? Are your nails brittle? Notice a pitting pattern to nails? Have you ever had an infection of the nail or around the nail bed? Do you chew your nails? Do you have difficulty keeping nails clean? Do your nails appear dirty? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

29 Examination: Skin - Routine
Routine techniques: Inspect for general color and uniformity of color. Consistent over body surface except vascular areas. Whitish pink to olive tones to deep brown. Sun-exposed skin is darker. Note color, pigmentation, vascularity, bruising, lesions, discolorations, or unusual odors. Systematically inspect and palpate skin from head and neck to trunk, arms, legs, and back. Provide adequate lighting so that subtle changes are not missed. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

30 Examination: Skin – Routine (contd.)
Inspect skin for localized variations in color: Intentional: Tattoos, coining patterns. Normal localized variations: Pigmented nevi (moles), freckles, patches, striae (stretch marks secondary to weight gain or pregnancy). Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

31 Examination: Skin Palpation
Palpate skin for texture, temperature, moisture, mobility, turgor, and thickness. Texture: Smooth, soft, intact, even surface, with calluses on hands, feet, elbows, and knees. Temperature and moisture: Warm and dry. Mobility and turgor: Should move easily when lifted, with immediate return after released. Thickness: Varies with age and area. Palms and soles thickest. Eyelids thinnest. Callus: Thick from friction and pressure. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

32 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Examination: Hair Inspect and palpate scalp and hair for surface characteristics, hair distribution, texture, quantity, and color. Surface characteristics: Smooth without flaking, scaling, redness, or lesions. Should be shiny and soft. Quantity and distribution: Balding patterns and hair loss; male patterned. Inspect facial and body hair for distribution, quantity, and texture. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

33 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Examination: Nails Inspect for nails for shape, contour, color, consistency, thickness, and cleanliness. Edges: Smooth and rounded. Contour: Flat and slightly rounded. Consistency: Note grooves, depressions, pitting, and ridges. Color: Pink, blanched in light-skinned patients; yellow or brown with vertical lines in dark-skinned patients. Thickness: Smooth, uniform. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

34 Age-Related Variations: Infants and Children
Assessment of skin among infants and children follow same general principals as described for adults. Skin lesions common to infants and children include: Milia Erythema toxicum Diaper rash Rashes associated with allergens Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

35 Age-Related Variations: Adolescents
Acne is the most common and worrisome skin lesion common to adolescents because of increases in sebaceous gland activity. Lesions are not only painful, but may also worry patient because of personal appearance. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

36 Age-Related Variations: Older Adults
Skin and hair undergo significant changes with aging. Lesions are commonly found on older adults. Although many lesions are considered expected variations associated with the aging process, incidences of skin cancer increase with age. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

37 Patients with Limited Mobility: Hemiplegia, Paraplegia, Quadriplegia
Patients with limited mobility are at risk for skin breakdown. Secondary to pressure and body fluid pooling because of inability to feel pressure or decreased ability to change position to relieve pressure. Examine patient’s skin, especially over bony prominences, and turn patient so that complete skin assessment may be performed. Patients who operate wheelchairs are at high risk for developing hand calluses; care should be taken to examine patient’s hands. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

38 Patients with Limited Mobility: Expected and Abnormal Findings –Skin
Assess all contact and skin pressure points for patients who have limited mobility: When a red area of skin is noted, blanch skin by applying gentle pressure over red areas. If skin becomes white when pressure applied and resumes red appearance after pressure relieved, circulation is sufficient and redness will disappear. If skin does not blanch when pressure applied, a stage I pressure ulcer has developed. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

39 Patients with Limited Mobility: Pressure Ulcers
Pressure ulcers are staged as follows: Stage I = Prolonged redness with unbroken skin. Stage II = Partial-thickness skin loss appears as a shallow, open ulcer with pink wound bed. Stage III = Full-thickness skin loss with damage to subcutaneous tissue (may note serosanguineous drainage). Stage IV = Full-thickness skin loss with exposed bone, muscle, or tendon – may have some eschar or slough. Unstagable = Eschar or slough may cover the entire wound bed; thus, it is unstagable. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

40 Common Problems and Conditions: Skin
Hyperkeratosis: Clavus (corn). Dermatitis: Variety of superficial inflammatory conditions: Atopic: Superficial inflammation. Contact: Inflammatory reaction to irritant or allergen: Localized erythema. May weep, ooze, or crust. Seborrheic: Chronic inflammation: Scaly, white, or yellowish skin on scalp, eyebrows, ears, axillae, chest, or back. Stasis: Inflammation seen mostly on lower legs of older adults: Areas of scaling, petechiae, and brown pigmentation. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

41 Common Problems and Conditions: Skin (contd.)
Psoriasis: Usually develops by age 20 years. Slightly raised erythematous plaques with silvery scales. Mostly on elbows, knees, buttocks, lower back, and scalp. Pityriasis rosea: Acute, self-limiting disease of young adults in winter. Thought to be viral. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

42 Common Problems and Conditions: Lesions Caused by Viral Infections
Warts – caused by HPV. Herpes simplex – group of 8 DNA viruses. Outbreaks triggered by sun exposure, stress, fever. Grouped vesicles with an erythematous base. Very painful and highly contagious Eruptions last about 2 weeks Herpes varicella – Chickenpox Lesions erupt in crops Painful and highly contagious Infectivity lasts about 6 days after final eruptions Herpes zoster – Shingles Grouped lesions along sensory nerve line Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

43 Common Problems and Conditions: Lesions Caused by Fungal Infections
Tinea infections: Tinea corporis – Ringworm. Tinea cruris – “Jock itch.” Tinea capitis – scaling and balding. Tinea pedis – “Athlete's foot.” Candidiasis: Affect superficial layers of skin and mucous membranes. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

44 Common Problems and Conditions: Lesions Caused by Bacterial Infections
Cellulitis – acute streptococcal or staphylococcal infection of the skin and subcutaneous tissue. Impetigo – highly contagious Group A streptococcal infection. Generally occurs on face, around mouth and nose. Folliculitis – inflammation of hair follicles. Furuncle (abscess or boil) – staphylococcal infection. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

45 Common Problems and Conditions: Lesions Caused by Arthropods
Scabies – highly contagious mite Sarcoptes scabiei. Lyme disease – tick infected with Borrelia burgdorferi. Spider bites – majority from black widow or brown recluse spiders. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

46 Common Problems and Conditions: Neoplasia
Basal cell carcinoma – most common: Locally invasive; rarely metastasizes. Nodular pigmented lesions with depressed center and rolled borders. Squamous cell carcinoma: Initially appears as a red, scaly patch. Melanoma – most serious: Malignant proliferation of melanocytes. Irregularly shaped with color variations. Kaposi’s sarcoma: Develops in connective tissue of immunosuppressed. Dark blue-purple macules, papules, nodules, and plaques. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

47 Common Problems and Conditions: Lesions Caused by Abuse
Bruise: Discoloration from blood seeping into tissues resulting from trauma. Bites Burns Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

48 Common Problems and Conditions: Hair
Pediculosis (lice): Lice on the body are called Pediculosis corporis. Pubic lice are called Pediculosis pubis. Alopecia areata: Chronic inflammatory disease of hair follicles resulting in hair loss on scalp. Hirsutism: Increase in growth of facial, body, or pubic hair in women. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

49 Common Problems and Conditions: Nails
Onychomycosis: Fungal infection of nail plate caused by Tinea unguium. Paronychia: Acute or chronic infection of cuticle caused by staphylococci and streptococci, although Candida may be causative organism. Ingrown toenail: Occurs when nail grows through lateral nail and into skin. Usually involves great toe. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

50 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Question 1 As the nurse performs a respiratory assessment, he notes a mole on the patient’s back over the right scapula. What is most important for the nurse to ask the patient? “Do you sleep on your right side?” “Does your bra strap rub this mole?” “Has this mole changed recently?” “Have you applied any creams to this mole?” Correct Answer: C Rationale: Although moles can become irritated with certain habits or by clothing, it would be more important for the nurse to ask about recent changes. A recent change could be an indication that a malignancy is present. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 50

51 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Question 2 A pustule is noted over the maxilla of the patient. Which of the following illustrates a pustule? A. B. Correct Answer: B Rationale: “A” displays wheals of urticaria. “C” displays keloids. “D” displays a blister. C. D. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 51

52 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Question 3 An 82-year-old patient is brought to the emergency department with suspected broken right hip. It is believed that she was lying between the bed and the wall for more than 48 hours before she was found. As the nurse conducts an assessment, the following condition over the lower back or coccyx area is seen. What should the nurse document related to this finding? Ecchymosis over coccyx Scaling lesion with exudate over coccyx Stage 2 pressure ulcer Stage 4 pressure ulcer Correct Answer: C Rationale: Ecchymosis refers to bruising. Scaling refers to dry skin, and exudate is a fluid that is weeping from a wound. This wound does not appear to have any weeping. Stage 2 pressure ulcers include loss of the epidermis; a stage 4 pressure ulcer will include loss or damage to muscle, bone, or both. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 52

53 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Case Study 1 Silas is a 2-year-old male child who attends day care. He has eight siblings at his home. All of his immunizations are up to date. He has a history of strep throat and RSV. His favorite activity is block stacking. His mother reports that he is generally a happy baby who is starting to become potty trained. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

54 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Case Study 1 (contd.) Subjective data: Complains of painful rash on R calf that is spreading to lower legs. Mother says the rash has been there for 1 week. Mother admits to trying oatmeal baths to stop the pain, but says this has not helped. Objective data: Vital signs: T 96.4; P 71; R 14. Height: 2’0. Weight 40 lb. R calf has a dime-sized, honey-crusted sore. R calf has become increasingly more irritated over the past week. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

55 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Case Study 1 (contd.) Questions: What risk factors does Silas have for impetigo? What measures might have helped prevent impetigo? What should the nurse do in this clinical situation? Prioritize actions. Risk factors present for Impetigo are: Attending day care. Having multiple siblings in the home. What measures might have helped to prevent impetigo? Instruct parent on proper cleansing of skin on a daily basis. Instruct parent to discuss cleaning protocols with the school. Wash all bed linens in hot water. Appropriate actions in this situation would be as follows: Assess for patient and familial understanding of teaching. Include his siblings in the proposed interventions and plan. Assess for medicine compliance. Make sure family and school understand the importance of hand washing. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

56 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Case Study 2 Sidney is a 4-year-old male child, who attends preschool. He has five siblings at his home. All of his immunizations are up to date. He has a history of otitis media and RSV. His favorite activity is sandbox play. He reportedly plays most of the day in the sandboxes at school. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

57 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Case Study 2 (contd.) Subjective data: Complains of itching, circular, rash behind his left ear. Mother says the rash has been there for 4 days. Mother admits to trying Vaseline to stop the itching, but says this made it worse. Objective data: Vital signs: T 97.2; P 68; R 16. Height: 4’0. Weight 70 lb. L ear rash has classic ring-worm shape with scaly appearance that spreads to his hairline. No drainage. The rash is quarter sized. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

58 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Case Study 2 (contd.) Questions:  What risk factors does Sidney have for Tinea capitis? What measures might have helped prevent Tinea capitis? What should the nurse do in this clinical situation? Prioritize actions. Answers: Risk factors present for tinea capitis are: Attending preschool. Having multiple siblings in the home. Playing in sandboxes and dirt at school daily. What measures might have helped to prevent Tinea capitis? Instruct parents on proper cleansing of scalp and skin on a daily basis. Instruct parents to discuss cleaning protocols with the school. Keep other children in the home from sharing hair-related items. Wash all bed linens in hot water. Appropriate actions in this situation are as follows: Assess for patient and familial understanding of teaching. Include his siblings in the proposed interventions and plan. Assess for compliance with taking medicines. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

59 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
The End Copyright © 2013 by Mosby, an imprint of Elsevier Inc.


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