Chapter 11—Skin, Hair, and Nails Assessment

Chapter 11—Skin, Hair, and Nails Assessment

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

Structure and Function
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—(cont.)
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

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

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

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

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—(cont.)
Figure 11.1

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

Cultural Considerations
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—(cont.)
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

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 SSE procedure 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 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 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
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—(cont.)
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 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 Rationale: Elderly patients need to bathe less often, usually every 2 to 3 days.

NCLEX-Style Review Questions
The nurse is admitting a 75-year-old man with a 50-year history of smoking one pack of cigarettes per day. Among the patient's concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is pitting. thickening and discoloration of the nail bed. clubbing. brittleness and cracking of the nails.

All of the following skin lesions are papular except warts. acne. moles. herpes zoster.

The ABCDs of melanoma identification include (select all that apply) Asymmetry: one half does not match the other half. Birthmark: recently changed in appearance. Color: pigmentation is not uniform; there may be shades of tan, brown, and black as well as red, white, and blue. Diameter: greater than 6 mm.

A nurse observes a skin lesion with well-defined borders on the upper left thigh. It is 1.5 cm in diameter, flat, hypopigmented, and nonpalpable. What is the correct terminology for this lesion? Patch Plaque Papule Macule

When assessing hydration, the nurse will pinch a fold of skin on the medial aspect of the forearm and observe for recoil to normal. pinch a fold of skin on the abdomen and observe for recoil to normal. pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal. pinch a fold of skin on the head and allow for skin to recoil in children.

A fair-skinned, blonde, 18-year-old woman is at the clinic for a skin examination. She reports that she always turns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. Which of the following would be included in the teaching? Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer. Apply a sunscreen or sunblock at least 15 to 30 minutes before sun exposure. Avoid sun exposure between 10 am and 4 pm to reduce UVA and UVB exposure. A mild sunburn is acceptable in a fair-skinned blonde person.

Rationale: Teaching the patient about the harmful effects of UVA and UVB exposure will help her understand the importance of sun protection. Sunscreens or sunblocks applied in time for the skin to fully absorb them afford the best protection. Avoiding the sun during the midday decreases exposure to intense and harmful UVA and UVB rays.

A patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow, ulcerated surface; some have scabbed over. The nurse suspects which of the following infectious illnesses? Varicella Measles Roseola Herpes simplex

Rationale: Varicella (chicken pox) is a highly contagious infectious disease. It occurs most frequently in children. It is characterized by single to multiple erythematous vesicles anywhere on the body. As the disease progresses, the vesicles progress into shallow ulcers covered with scabs. Measles is a rash of macules and papules. Herpes simplex is generally localized to one area of the body and consists of grouped vesicles on an erythematous base. Roseola is a macular and papular rash.

A 24-year-old patient reports an itchy red rash under her breasts. Examination reveals large, reddened, moist patches under both breasts in the skin folds. Several smaller, raised, red lesions surround the edges of the larger patch. What is the correct terminology for the distribution pattern of these smaller lesions? Satellite Discrete Confluent Zosteriform

Rationale: Single lesions in close proximity to a larger lesion are termed satellite lesions. Discrete distribution identifies lesions that are totally separate from one another. Confluent lesions are several lesions that have merged together, and zosteriform distribution identifies lesions, which follow a dermatomal pathway.

A 22-year-old patient presents to the clinic with a large firm mass on her left earlobe. She had her ears pierced approximately 3 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 2.5 cm (1 in.) in diameter. It is not tender, reddened, or seeping any drainage. What is the term used to describe this secondary skin lesion? Crust Lichenification Keloid Scale

Rationale: Keloid is an excessive accumulation of fibrin tissue in response to wound healing. Lichenifications are exaggerated skin lines as a result of chronic irritation or scratching. Crust is a dried secretion from a primary lesion, and a scale results from excessive proliferation of the upper epidermal skin layers without normal shedding of dead cells.

An 83-year-old woman is undergoing a routine physical examination. Which of the following assessment findings would the nurse consider an expected age-related variation? Thinning of the skin Increased skin turgor Hypopigmented flat macules and patches over sun- exposed areas Multiple purplish bruises on the arms and legs

Rationale: The skin layers thin with aging, resulting in decreased skin turgor. Thinned skin is subject to increased trauma from shearing or friction, which increases the risk for purpuric lesions. Nevertheless, such lesions are not a normal variant of aging skin. Hyperpigmented macules and papules (commonly seborrheic keratoses) are present on sun-damaged skin.

A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion? Papule Pustule Cyst Vesicle

Chapter 12—Head and Neck, Including Lymph Nodes and Vessels

Introduction Head, neck regions
Scalp; cranium; lymphatic system; parathyroid, thyroid glands Chapter contents Data collection methodology Signs/symptomology Parathyroid, thyroid imbalances Correct techniques for inspection and palpation Common expected and unexpected findings

Structure and Function
Structures interact with multiple body systems. Integumentary; neurological; respiratory; vascular; gastrointestinal; lymphatic; endocrine Head Skeletal structure; muscles; blood supply; nerve supply; salivary glands Neck (C1–C7) Trachea Thyroid, parathyroid glands Lymphatics

Lifespan Considerations: Older Adults
Bony structures more pronounced D/T decreased subcutaneous fat Skin lesions more likely Careful assessment for skin cancers, especially in commonly sun-exposed areas Hypothyroidism/hyperthyroidism more common Hypothyroidism > Hyperthyroidism Cultural considerations

Urgent Assessment Acute head injuries and neurologic changes
Stabilization of head, neck; trauma assessments Neck pain: usually muscle tension, spasm Beware: fever + headache; possible cardiac Lymphatics > 1 cm; fixed, irregular, hard or rubbery Require emergency investigation for cancer Hyperthyroidism: “thyroid storm”, “thyroid crisis” Hypermetabolism in all systems

Subjective Data Collection
Multiple systems may influence structure, function Assessment of risk factors Personal history Medications Family history Risk reduction and health promotion Reducing injury risk Preventing thyroid disorder complications Early detection of masses or malignant lymph nodes

Common Symptoms Common head, neck symptoms Headache; neck pain
Limited neck movement Facial pain Lumps/masses Hypo/hyperthyroidism Lifespan considerations: older adults Cultural considerations

Objective Data Collection
Equipment; preparation Common and specialty or advanced techniques Head-to-toe assessment Comprehensive physical examination Inspection: head; hair; neck Palpation Head: temporal artery + pulse; scalp Neck: thyroid; head, neck lymph nodes; cervical spine; neck, in general Auscultation: enlarged thyroid only

Critical Thinking Common laboratory and diagnostic testing
CT; MRI; lumbar puncture; thyroid labs: TSH, T3, T4 Diagnostic reasoning: Nursing diagnosis, outcomes, and interventions Outcomes (partial list) Patient verbalizes increased energy, well-being. Pain goals are met. Interventions (partial list) Allow for period of rest before planned activity. Set small, achievable short-term activity goals

Question Is the following statement true or false? An expected finding with neck palpation is lymph nodes larger than 1 cm in size.

Answer Rationale: Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer.

While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next? Document this finding as normal. Tell the patient that this finding is unexpected. Report to the physician a suspicion of a slow growing goiter. Look for signs of hypothyroidism.

The lymph nodes that lie in front of the mastoid bone are the: Preauricular nodes Occipital nodes Superficial cervical nodes Supraclavicular nodes

Which of the following descriptions is most consistent with a patient who has hypothyroidism? Slightly obese, perspiring female, who complains of feeling cold all the time and having diarrhea Slightly obese female with periorbital edema and a flat facial expression, who complains of constipation, deceased appetite, and fatigue Thin, anxious-appearing female with exophthalmos and a rapid pulse, and who complains of diarrhea Thin, perspiring male with a deep hoarse voice, facial edema, a thick tongue, and reports of diarrhea

Rationale: The patient with hypothyroidism would likely demonstrate clinical signs and symptoms of a low metabolic rate resulting from relative depletion of circulating thyroid hormone.

Physical examination of a patient reveals an enlarged tonsillar node. Acutely infected nodes would be Hard and nontender Fixed and soft Firm but movable and tender Irregular and hard

While assessing the skin of a 24-year-old patient, the nurse notes decreased skin turgor. The nurse should further assess for signs and symptoms of hyperthyroidism hypothyroidism malnutrition dehydration

The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient clench his or her teeth during muscle palpation bring his or her head to the chest turn his or her head against resistance extend his or her arms against resistance

Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach? Please tilt your head back as far as possible. Please turn your head as far to the right as you can. Please bring your chin down toward your neck. Please tilt your head slightly down and to one side.

While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action? Recognize that it is not common to palpate lymph nodes in this region and they must be carefully evaluated. Recognize that a palpable node in this region is a dangerous indication of metastatic cancer that requires further evaluation. Recognize that this is a common area for lymph nodes to be enlarged with minor infections. Recognize that a palpable lymph node in this region is always indicative of malignancy.

Rationale: Cancers of the lung, breast, and abdomen may metastasize to the lymph nodes and be first accessible during clinical assessment in the supraclavicular region.

While reviewing laboratory values for thyroid function on an adult patient, the nurse sees that the TSH is elevated, and the T3 and T4 are decreased. The nurse recognizes that these findings are indicative of normal thyroid function hypothyroidism hyperthyroidism thyroid cancer

A patient presents with a complaint of drooping of his eyes, cheeks, and mouth on one side. This finding is most likely associated with pathology of which cranial nerve? Cranial nerve III Cranial nerve V Cranial nerve VII Cranial nerve IX

Chapter 11—Skin, Hair, and Nails Assessment

Similar presentations

Presentation on theme: "Chapter 11—Skin, Hair, and Nails Assessment"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Chapter 11—Skin, Hair, and Nails Assessment

Similar presentations

Presentation on theme: "Chapter 11—Skin, Hair, and Nails Assessment"— Presentation transcript:

Similar presentations

About project

Feedback