copyright © 2014 wolters kluwer health | lippincott williams & wilkins weber health assessment...

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

WeberHealth Assessment in Nursing

WeberHealth Assessment in Nursing

Chapter 14: Assessing Skin, Hair, and Nails


Structure and Function of SkinStructure and Function of Skin

• 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.


Skin, Hair and NailsSkin, Hair and Nails

• Skin- epidermis, dermis, subcutaneous layers

• Hair- vellus, terminal

• Nails- hard, transparent plates of keratinized epidermal cells


QuestionQuestion

Is the following statement True or False?

Sebum has some fungicidal and bactericidal effects.


AnswerAnswer

True.

Sebum has some fungicidal and bactericidal effects.


QuestionQuestion

Is the following statement True or False?

Asians and Native Americans have strong body odor.


AnswerAnswer

False.

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.


Skin CancerSkin Cancer

• Most common of cancers

• Three types: melanoma, basal cell carcinoma, squamous cell carcinoma

• Asians are less susceptible


Risk Factors of Skin CancerRisk Factors of Skin Cancer• Sun exposure

• Nonsolar sources of ultraviolet radiation

• Medical therapies

• Family history and genetic susceptibility

• Moles

• Pigmentation irregularities

• Fair skin that burns and freckles easily; light hair

• Age


Risk Factors of Skin Cancer (Cont’d)Risk Factors of Skin Cancer (Cont’d)• Male gender

• Chemical exposure

• Human papillomavirus

• Xerodrem pigmentosum

• Long-term skin inflammation or injury

• Alcohol intake; smoking

• Inadequate niacin in diet


Risk Reduction in Skin CancerRisk Reduction in Skin Cancer• Reduce skin exposure

• Always use sunscreen when sun exposure is anticipated

• Wear long-sleeve shirts and wide-brimmed hats

• Avoid sunburns

• Understand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on developing cancers

• Have annual skin cancer screenings


Risk Reduction in Skin CancerRisk Reduction in Skin Cancer• Ensure diet is adequate in vitamin B3

• Examine the skin for suspected lesions

– Use the ABCDE mnemonic to assess suspicious lesions:

– Asymmetry

– Border

– Color

– Diameter

– Elevation


QuestionQuestion

Which skin disorder may be caused by exposure to the sun?

a. Acne

b. Cancer

c. Vitiligo

d. Warts


AnswerAnswer

b. Cancer.

Rationale: Skin cancer may be caused by exposure to the sun. Acne, vitiligo, and warts are not caused by sun exposure.


Cultural Variations in Skin CancerCultural Variations in Skin Cancer

• Lowest rates: Asians

• Highest rates: white Australians

• Most susceptible are people with pale white, freckled skin and red hair


Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUSRisk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

• Assess for hospital-acquired MRSA risk factors:

– Having an invasive medical device

– Residing in a long-term care facility


Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (CONT.)Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (CONT.)

• Assess for community-acquired MRSA risk factors:

– Participating in contact sports

– Sharing personal items such as towels or razors

– Suppression of the immune system function (e.g. HIV, cancer, or chemotherapy)

– Residing in unsanitary or crowded living conditions (dormitories or military barracks)


Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (CONT.)Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (CONT.)

• Working in the health-care industry

• Receiving antibiotics within the past 3 to 6 months

• Young or advanced age

• Men having sex with men


Measures to Reduce Risk FactorsMeasures to Reduce Risk Factors• Keep 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.


Nursing History: Present Health ConcernNursing History: Present Health Concern

• Body odor problems

• Skin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation)

• Changes in lesion appearance

• Feeling changes (pain, pressure, itch, tingling)

• Hair loss or changes

• Nail changes


Nursing History (cont.)Nursing History (cont.)

• Personal health history

• Family history

• Lifestyle and health practices

• Exposure to sun or chemicals

• Daily care of skin, hairs, nails

• Usual diet and exercise patterns


Client PreparationClient Preparation

• Ask the client to remove all clothing and jewelry

• Have the client sit comfortably• Ensure privacy• Maintain comfortable room

temperature


EquipmentEquipment

• Gloves• Examination light and penlight• Magnifying glass• Centimeter ruler• Wood’s light• Examination gown or drape


Skin Assessment: InspectionSkin Assessment: Inspection

• Note any distinctive odor

• Generalized color variations

• Skin breakdown

• Primary, secondary, or vascular lesions


Skin Assessment: PalpationSkin Assessment: Palpation

• Lesions

• Texture

• Temperature and moisture

• Thickness of skin

• Mobility and turgor

• Edema


Pressure Ulcer Risk FactorsPressure Ulcer Risk Factors

• Perception

• Mobility

• Moisture

• Nutrition

• Friction or shear against surfaces

• Tissue tolerance decreased


Pressure Ulcer Risk ReductionPressure Ulcer Risk Reduction

• Inspect 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.


Pressure Ulcer Reduction (cont.)Pressure Ulcer 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.


Scalp and HairScalp and Hair

• Inspection and palpation

– General color and condition, cleanliness, dryness or oiliness, parasites, and lesions

– Amount and distribution of scalp, body, axillae, and pubic hair


Nail AssessmentNail Assessment

• Nails

– Inspection: Nail grooming and cleanliness, nail color and markings, shape of nails,

– Palpation: Texture, assess texture and consistency, capillary refill


Nails Risk FactorsNails Risk Factors• Nails in moist environment, especially walking in damp

public locales or continuously wearing closed shoes; excessive perspiration.

• Nail injury, trauma, or irritation

• Immune system disorders such as diabetes mellitus and AIDS or on immunosuppressive medications.

• Skin conditions such as psoriasis or lichen.

• Some trades or professions

• Contagion from one digit to another or one person to another.

• Possibly family predisposition.


Nails Risk Reduction TipsNails Risk Reduction Tips

• Wear 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.


Physical Assessment (cont.)Physical Assessment (cont.)

• Capillary refill

• Hair color and texture

– Individuals of black American descent often have very dry scalps and dry, fragile hair.


Self-Assessment Skin, Hair, NailsSelf-Assessment Skin, Hair, Nails

• Refer to Box 14.1 Self Assessment: How to Examine Your Own Skin


Normal and Abnormal FindingsNormal and Abnormal Findings

• Share outcomes of assessment with peers


Pressure Ulcer StagesPressure Ulcer Stages

• Stage One

• Stage Two

• Stage Three

• Stage Four

• Unstagable


Primary Skin LesionsPrimary Skin Lesions

• Macule and Patch

• Papule and Plaque

• Nodule and Tumor

• Vesicle and Bulla

• Wheal

• Pustule

• Cyst


Secondary Skin LesionsSecondary Skin Lesions

• Erosion

• Ulcer

• Sacr

• Fissure


Vascular Skin LesionsVascular Skin Lesions

• Petechia

• Ecchymosis

• Hematoma

• Cherry Angioma

• Spider Angioma

• Telangiectasis


Common Nail DisordersCommon Nail Disorders

• Longitudinal ridging

• Half and half nails

• Pitting

• Koilonychia

• Yellow nail syndrome

• Paronychia


Common Changes AgingCommon Changes Aging

• Skin

– Pale

– Skin lesions

– Dry

– Loses turgor

• Hair: Thinner

• Nails: Thickened, yellow, brittle


Validating and Documenting FindingsValidating and Documenting Findings

• Health promotion diagnoses

• Risk diagnoses

• Actual diagnoses

• Collaborative problems

• Medical problems

copyright © 2014 wolters kluwer health | lippincott williams & wilkins weber health assessment...

Documents

skin exposure

function of skin

skin disorder

diet slide

susceptible slide

nails skin epidermis

annual skin cancer screenings

light hair age slide