principles to remember

PRINCIPLES TO REMEMBER1. Any break or disruption of the skin predisposes the

client to infection.

2. The hydration of the skin and mucous membranesreveals the body ’ s ability to regulate bodytemperature.

3. Skin temperature changes can reflect alterations inblood flow.

4. Specific skin conditions or underlying diseasesmay be detected.

5. Condition of the skin reflects the level of a person’shygiene.

EQUIPMENT TO BE USED

CLIENT PREPARATION• Ask the client to remove all clothing and jewelry

then put on the examination gown.

• Ask the client to remove nail enamel, artificialnails, wigs, and hairpieces as appropriate.

• Provide clear and appropriate instructions.

• Position: sitting on the examination table or bed;lateral or prone for assessing skin on buttocksand dorsal surfaces of legs.

Key Points To Remember

• Inspect skin color, temperature, moistureand texture.

• Check skin integrity.

• Be alert for skin lesions.

• Evaluate hair condition, loss or unusualgrowth.

• Note nail bed condition and capillary refill.

INSPECTION

• Inspect general skin coloration.

–While inspecting skin coloration, noteany odors emanating from the skin.

–Melanin pigments account for skincolor intensity.

ACANTHOSIS NIGRICANS

VITILIGO

Color Condition Cause Assessment Location

Cyanosis

(bluing)

Increased amount of

deoxygenated

hemoglobin, associated

with hypoxia

Heart or lung

disease; cold

environment

Nail beds

(peripheral

cyanosis); lips;

mouth; skin (severe

cases of central

cyanosis)

Pallor

(decrease in

skin color)

Reduced amount of

oxyhemoglobinAnemia Face; conjunctiva;

nailbeds

Reduced visibility of

oxyhemoglobin as a

result of decreased

blood flow

ShockSkin; nail beds;

conjunctiva; lips

Congenital or

autoimmune condition

causing lack of

pigment

VitiligoPatchy areas

on the skin

PERIPHERAL CYANOSIS

CENTRAL CYANOSIS

ACROYANOSIS

Jaundice

(yellow-orange)

Increase deposition of

bilirubin in the tissues

Liver, gallbladder, or

pancreatic disease;

destruction of RBC

Sclera; mucous

membranes; skin

Erythema

(redness)

Increased visibility of

oxyhemoglobin as a

result of dilation or

increased blood flow

Fever; direct

trauma; blushing;

alcohol intake

Face; area of

trauma

Tan-brown Increased amount of

melanin

Suntan; pregnancy

or Addison’s

disease

Areas exposed to

sun; face; areola;

nipples

Ecchymosis

(black and blue)

Extravasation of blood

into the subcutaneous

tissue

Trauma or fragile

blood vessels

Extremities, head,

or trunk in areas

easily exposed to

injury

Hyperpigmentation in Addison’s disease

INSPECTION

• Inspect for color variations

• Inspect localized parts of the body,noting any color variation.

ALBINISM

DISCOID LUPUS ERYTHEMATOSUS

INSPECTION

• Check skin integrity• Give special attention to pressure point

areas.

• Use a scale to document the degree ofskin breakdown if present.

• For obese clients: inspect skin on limbs,under breasts, & in the groin area.

• Some risk factors for skinbreakdown leading to pressureulcers include:– Poor circulation

– Poor hygiene

– Infrequent position changes

– Dermatitis

– Infection

– Traumatic wounds

erosion

vesicle

• Ulcer resembles a

massive crater

INSPECTION

• Inspect for lesions• Note the color, shape, and size.

• Note the location, distribution, andconfiguration.

• If suspecting a fungal infection, shine thearea with wood’s light.

Appearance of fungal infection(using Wood’s lamp illumination)

• Primary Skin Lesions: original lesions frompreviously normal skin

• Secondary Skin Lesions: originates fromprimary skin lesions

• Vascular Skin Lesions: lesions associatedwith bleeding, aging, circulatoryconditions, diabetes, pregnancy andhepatic diseases

1.Macule and Patch2.Papule and Plaque3.Nodule and Tumor4.Vesicle and Bulla5.Wheal6.Pustule7.Cyst

Macule, Patch

Flat, non-palpable skin color change (skin

color may be brown, white, tan, purple,

red)

Macule: <1cm, circumscribed border

Patch: >1cm, may have irregular border

Examples:

Freckles

Flat mole

Petechiae

Rubella

Vitiligo

Port wine stains

Ecchymosis

Papule and Plaque

An elevated, palpable solid mass, with a

circumscribed border

Papule: <0.5cm

Plaque: >0.5cm (may be coalesced

papules with a flat top)

Examples:

Papules:

Elevated nevi

Warts

Lichen planus

Plaques:

Psoriasis

Actinic keratosis

Nodule and Tumor

Elevated, solid, palpable mass

Extends deeper into dermis than a papule

Nodule: 0.5-2cm; circumscribed

Tumor: >1.2cm; doesn ’ t always have

sharp borders

Examples:

Nodules:

Lipoma

Squamous cell carcinoma

Poorly absorbed injection

Dermatofibroma

Tumors:

Larger lipoma

Carcinoma

DERMATOFIBROMA

LIPOMA

Vesicle and Bulla

Circumscribed, elevated,

palpable mass, containing

serous fluid

Vesicle: <0.5cm

Bulla: >0.5cm

Examples:Vesicles:

Herpes Simplex/Zoster

Varicella (Chickenpox)

Poison Ivy

Second-degree burn

Bulla:

Pemphigus

Contact dermatitis

Large burn blisters

Poison ivy

Bullous impetigo

HERPES ZOSTER

POISON IVY

PEMPHIGUS

CONTACT DERMATITIS

BULLOUSIMPETIGO

Wheal

Elevated mass with transient borders

Often irregular

Size and color vary

Caused by movement of serous fluid into the

dermis

Does not contain free fluid in a cavity (e.g.

vesicle)

Examples:

Urticaria (hives)

Insect bites

Pustule

Pus-filled vesicle or bulla

Example:

Acne

Impetigo

Furuncles

Carbuncles

Cyst

Encapsulated fluid-filled or semisolid mass

Located in the subcutaneous tissue or

dermis

Example:

Sebaceous cyst

Epidermoid cyst

PRIMARY SKIN LESIONS

PORT WINE STAIN

PETECHIAE

RUBELLA

LICHEN PLANUS

PSORIASIS

ACTINIC KERATOSIS

FURUNCLE

CARBUNCLE

1. Erosion2. Ulcer3. Scar (Cicatrix)4. Fissure5. Scales6. Crust7. Keloid8. Atrophy9. Lichenification

Erosion

Loss of superficial epidermis

Does not extend to the dermis

Depressed, moist area

EXAMPLE:

Ruptured vesicles

Scratch marks

Aphthous ulcer

APHTHOUS ULCER

Ulcer

Skin loss extending past epidermis

Necrotic tissue loss

Bleeding and scarring possible

EXAMPLE:

Stasis ulcer of venous

insufficiency

Pressure ulcer

Scar (Cicatrix)

Skin mark left after healing of wound or lesion

Represents replacement by connective tissue of

the injured tissue

Young scars: red or purple

Mature scars: white or glistening

EXAMPLE:

Healed wound

Healed surgical incision

Fissure

Linear crack in the skin

May extend to the dermis

EXAMPLE:

Chapped lips or hands

Athlete’s foot

Scales

Flakes secondary to desquamated, dead

epithelium

Flakes may adhere to skin surface

Color varies (silvery, white)

Texture varies (thick, fine)

EXAMPLE:

Dandruff

Psoriasis

Dry skin

Pityriasis rosea

PITYRIASIS ROSEA

Crust

Dried residue of serum, blood, or pus on

skin surface

Large adherent crust is a scab

EXAMPLE:

Residue left after vesicle

rupture

Impetigo

Herpes

Eczema

Keloid

Hypertrophied scar tissue

Secondary to excessive collagen

formation during healing

Elevated, irregular, red

Greater incidence in African Americans

EXAMPLE:

Keloid of ear piercing

Keloid of surgical incision

Atrophy

Thin, dry, transparent appearance of

epidermis

Loss of surface markings

Secondary to loss of collagen and elastin

Underlying vessels may be visible

EXAMPLE:

Aged skin

Arterial insufficiency

Lichenification

Thickening and roughening of the skin

Accentuated skin markings

May be secondary to repeated rubbing,

irritation, scratching

EXAMPLE:

Contact dermatitis, often

resulting from exposure to

aero allergens, chemicals,

foods, and emotional stress

1. Petechia (Petechiae – plural)2. Ecchymosis (Ecchymoses – plural)3. Hematoma4. Cherry Angioma5. Spider Angioma6. Telangiectasis (Venous Star)

• Petechia (Petechiae – plural)• Round red or purple macule• Small: 1-2 mm• Secondary to blood extravasation• Associated with bleeding tendencies or emboli to skin

• Ecchymosis (Ecchymoses – plural)• Round or irregular macular lesion• Larger than petechia• Color varies and changes: black, yellow, and green hues• Secondary to blood extravasation• Associated with trauma, bleeding tendencies

1.HematomaA.A localized collection of blood creating an elevated ecchymosisB.Associated with trauma

•Hematoma

•A localized collection of blood creatingan elevated ecchymosis

•Associated with trauma

•Cherry Angioma• Papular and round• Red or purple• Noted on trunk, extremities• May blanch with pressure• Normal age-related skin alteration• Usually not clinically significant

• Spider Angioma• Red, arteriole lesion• Central body with radiating branches• Noted on face, neck, arms, trunk• Rare below waist• May blanch with pressure• Associated with liver disease, pregnancy and vitamin B deficiency

• Telangiectasis (Venous Star)

• Shape varies: spiderlike or linear• Color bluish or red• Does not blanch when pressure is applied• Noted on legs, anterior chest• Secondary to superficial dilation of venous vessels and capillaries• Associated with increased venous pressure states (varicosities)

Malignant melanoma is usually evaluated according to themnemonic ABCDE:

• A: Assymetry• B: Borders that are irregular (uneven or notched)• C: Color variations• D: Diameter exceeding 1/8 to 1/4 of an inch• E: Elevated, not flat

The most commonly detected skin cancers include:•Basal cell carcinoma•Squamous cell carcinoma•Kaposi’s Sarcoma

PALPATION

• Palpate skin to assess texture

• Palpate to assess thickness

• Palpate to assess moisture

• Palpate to assess temperature

• Palpate to assess mobility and turgor

• Palpate to detect edema

INSPECTION & PALPATION

• Inspect for general color and condition.

• Inspect and palpate the hair and scalp forcleanliness, dryness or oiliness, parasites,and lesions.

• Inspect amount and distribution of scalp,body, axillae, and pubic hair.

TINEA CAPITIS (SCALP RINGWORM)

FOLLICULITIS

PATCHY HAIR LOSS

HIRSUTISM

INSPECTION

• Inspect nail groomingand cleanliness.

• Inspect nail color andmarkings.

• Inspect shape of nails.

Beau’s Lines

Transverse depression in nails

indicating temporary disturbance of

nail growth (nails grow over for

several months)

CAUSES:

Acute illness

Systemic illness such as severe

infection or nail injury

Koilonychia / Spoon Nails

Concave curvature of the nails

CAUSES:

Iron-deficiency anemia

Syphilis

Use of strong detergents

Clubbing

Early clubbing (180 degrees)

Late clubbing (> 180 degrees)

Change in angle between nail and

nail base; nail bed softening, with

nail flattening often

CAUSES:

Chronic lack of oxygen due to heart

or any pulmonary disease

CLUBBING

Pitting

Pit formation on the nails

CAUSES:

Psoriasis

Splinter Hemorrhages

Red or brown linear streaks in nail

bed

CAUSES:

Minor trauma

Subacute Bacterial Endocarditis

Trichinosis

Paronychia

Inflammation of skin at the base of

the nail

CAUSES:

Local infection

Trauma

PALPATION

• Palpate nail to assess texture.

• Palpate to assess the texture andconsistency, noting whether nailplate isattached to nailbed.

• Test capillary refill in nailbeds bypressing the nail tip briefly andwatching for color change.

Sample Objective Data:

• Skin is pink, warm, dry and elastic

• (+) freckles across the nose and cheeks

• (--) lesions or excoriations

• (+) old appendectomy scar @ the RLQ, 4 in. long, thin, and white

• With brown hair of shoulder length, clean and shiny

• With evenly distributed hair along the scalp and perineum

• Nails form 160-degree angle at base, hard, smooth, and immobile

• Fingernails well manicured with clear enamel

• Toenails clean and well-trimmed

• (+) pink nailbeds without clubbing

• (+) smooth cuticles

• (--) nail plate detachment

• With good capillary refill @ 2 secs.

APPROPRIATE NURSING DIAGNOSES

• Wellness Diagnoses

– Readiness for enhanced skin, hair, and nailintegrity related to healthy hygiene and skin carepractices, avoidance of overexposure to sun

– Health-seeking behavior: Requests information onskin reactions and effects of using a sun-tanninglotion

• Risk Diagnoses

– Risk for impaired skin integrity related to excessiveexposure to cleaning solutions and chemicals

– Risk for impaired skin integrity related toprolonged sun exposure

– Risk for imbalanced body temperature related toimmobility, decreased production of natural oils,and thinning skin

– Risk for impaired skin integrity of toes related tothickened, dried toenails


– Risk for imbalanced body temperature related tosevere diaphoresis

– Risk for infection related to scratching of rash

– Risk for impaired nail integrity related toprolonged used of nail polish

– Risk for altered nutrition: Less than bodyrequirements related to increased vitamine andprotein requirements necessary for healing ofwound.


• Actual Diagnoses

– Ineffective health maintenance related to lack ofhygienic care of the skin, hair and nails

– Impaired skin integrity related to immobility anddecreased circulation

– Impaired skin integrity related to poor nutritionalintake and bowel/bladder incontinence

– Disturbed body image related to scarring, rash, orother skin condition that alters skin appearance


– Disturbed sleep pattern related to persistentitching of the skin

– Deficient fluid volume related to excessivediaphoresis secondary to excessive exercise andhigh environmental temperatures


PATIENT AND FAMILY EDUCATION WITH HOME

HEALTH TEACHINGS

SKIN

Instruct client how to reduce the risk of skincancer

Teach the client to conduct a monthly selfexamination of the skin

Tell the client to report to a physician any unusualchanges

Tell the client to apply alcohol-free lotion andmoisturizer regularly to the skin

Instruct adolescents on proper skin cleansing andthe importance of balanced diet and adequaterest.

HAIR and SCALP

• Instruct clients about basic hygiene measures,including shampooing and combing the hair.

• Instruct clients who have head lice to shampoothoroughly with a pediculicide, comb thoroughlywith fine-tooth comb, and discard comb

• Instruct the client who has lice about ways toreduce transmission

NAILSInstruct the client to cut nails only after soaking

them at least 10 minutes in warm water.

Caution client against the use of OTC preparations totreat corns, calluses, or ingrown toenails.

Tell client to cut nails straight across and even withtops of fingers and toes. If client has DiabetesMellitus, tell client to file, not cut, nails.

Instruct client to shape nails with a file or emeryboard.

principles to remember

Documents