NRS 103 Skin, Hair, and Nails Chapter 9

1. NRS 103 Skin, Hair, and NailsChapter 9 Nancy Sanderson MSN, RN

2. Integumentary System Skin and accessary structures (nails, hair sweat glands and sebaceous glands) form the integumentary system. The skin is elastic, self generating and covers the entire body. Primary function is to protect the body from microbial and foreign substance invasion and protect internal body structures from physical trauma. The skin also helps to retain body fluids and electrolytes, provides sensory input about the environment, regulation to body temperatures, excretion of sweat, lactic acid, urea, expressing emotions, ie: blushing, production of vitamin D, repairs own wounds by cell replacement and could tell us of internal disorders by providing valuable clues.

3. Skin Layers • Epidermis • Outermost layer. Barrier to external penetration • Dermis • Underneath epidermis. Sensory organ for touch, pressure, & temperature. Contains nerves that innervate glands & blood vessels • Subcutaneous • Under dermis. Stores fat, generates heat, provides temperature regulation

4. Skin: why all the concern! • May be an early sign warning • Jaundice—liver disease • Nails—anemia, trauma, hypoxia (per oxygenation) • Hives/Rash—allergy • Rash—infection; auto-immune disease; insect bites (viruses/bacteria/parasites); tumor (benign/malignant); etc., etc., etc. • Edema—heart or renal disease • Tears, fissures, pressure ulcers—injury; immobility

5. Health History • Any change in skin, hair, or nails? • Increase in hair loss, thinning, or breakage? • Nail splitting, thickening, discoloration, or separation from nail bed? • Any rashes, sores, lumps, or itching? • Any change in appearance of moles? • Any lesions that slow or fail to heal? • Assess risk factor for skin cancers • Sun exposure, blistering sunburns in childhood, family history, light skin, presence of atypical moles (dysplastic nevi), >50 common moles, or immunosuppresion

6. Health History • Skin, hair, or nail complaint specific • OLDCART of skin/hair/or nail complaint • What did rash /lesion look like when first appeared • Pain, pruritus, burning? • Previous or family hx of similar complaint? Resolution? Treatments? • Change in skin products, detergents, foods, medications? • What medications taking? • Any environmental or occupational hazards? • Change in nutrition status? • Recent life changes (Losses, psychological/ physical stress) or travel out of US? • Major health problems (severe cardiac, endocrine, respiratory, liver, hematologic, or other)?

7. Skin Exam Basics • General inspection of entire body, followed by detailed regional exam • Good source of lighting needed, indirect natural daylight preferred. • Consider using small magnifying glass to aid in examining lesions • Use clear flexible measure to assess size • Wear gloves for all skin examination! • Protect patient’s modesty while exposing areas as fully as possible • Remove socks to examine feet and between toes

8. Inspection & Palpation of Skin Color Temperature Moisture Texture Vascularity/bruising Edema Lesions

9. Color Establish baseline skin color by observing least pigmented skin surfaces (volar surface of forearm, palms/soles, abdomen, and buttocks) Vascular flush areas: cheeks, bridge of nose, neck, upper chest, flexor surfaces of extremities, genital areas (vascular disturbance, blushing, inc temp compare with less vascular areas) Pigment labile areas: face, back of hands, flexors or wrist, axillae, mammary areola, midline of abdomen, and genital area (acanthosis nigracans)

10. Color • Pigmentation changes • Cyanosis • Jaundice • Pallor • Erythema Skin color consistent with genetic background, in dark skin, color may be ashen-gray in mucous membranes

11. Cyanosis • A dusky blue color, may be visible in nail beds, lips, earlobes, & oral mucosa • In dark skinned- close inspection of nail beds, lips, palpebral conjunctiva, palms, and soles

12. Jaundice • A yellow or green hue • Often first visible in sclera, then mucous membranes, then skin • In dark skinned- May normally be slightly yellow. View posterior portion of hard palate for yellowish cast. Yellowish/green color in sclera, palms of hands, and soles of feet,

13. Pallor & Erythema • Pallor • Decreased color/red tone in skin. Skin pale • Most evident in face, palpebral conjunctiva, mouth, and nail beds • In dark skinned: Brown skin- yellowish brown tinge; Black skin- ashen gray. Absence of underlying red tones in skin. • Erythema • Intense redness of skin • In dark skinned: Difficult to see. Usually associated with increased temperature so palpation should be used to assess for inflammatory condition

14. Temperature • Temperature • Palpate with dorsal aspect of hand on both sides of body for comparison of patient’s skin temperature • Normal: Warm • depending on environment • Abnormal: • Increased: burn, localized infection, fever • Decreased: Circulatory problems, shock

15. Moisture & Texture • Moisture • Normal: Dry • influenced by environmental/body temp and muscular activity • Abnormal: Too moist vs Too dry (maceration) • Dryer in winter (decreased humidity) & with age • May indicate dehydration or thyroid disease • Texture • Normal: Smooth, firm, soft. Thickness varies in different areas • Abnormal: Loose, wrinkles, rough, thickened, thin, oily, flaking, scaling, indurated (hardened)

16. Signs and Symptoms of Dehydration • Altered mental status • Lethargy • Light headedness • Syncope • Decreased skin turgor • Dry mucus membranes • Orthostatic hypotension • Moderate oliguria or anuria • Resting hypotension **Aging- decreased body water from 60-40% because increased body fat and increased lean body mass. Impaired water conservation & sodium imbalance**

17. Lesions • Lesions • Traumatic or pathological changes in previously normal structures • Note: • Color • Location • Size in cm • Discharge (amount, color, odor) • Characteristics/Classification • Shape and configuration No lesions noted

18. Lesions, variations in skin color and nail beds The text book in chapter 9 has very good tables, pictures and descriptions of each condition, characteristics and abnormalities for various integumentary disorders. Please review and familiarize yourself with the definitions of lesions, nail beds and skin problems.

19. Cancers • Irregular Borders • Diameter of a malignant skin lesion is usually greater than 6 mm. • Melanoma is a variety of colors. • Basal Cell Carcinoma • Squamous Cell Carcinoma • Malignant Melanoma

20. Patient Education Monthly inspect skin & scalp noting moles, blemishes and birthmarks Contact health care provider if skin lesions begins to bleed, ooze, or feel different • A • Asymmetry • B • Borders irregular • C • Color variations • D • Diameter >6mm • E • Elevation—from flat to raised • F • Feeling –itching, tingling, or stinging

21. Patient Education • Prevention • Wear wide brimmed hat • Apply broad-spectrum sunscreen (UVA & UVB) with SPF of 15 or greater • Avoid tanning under the direct sun at midday • (10am-4pm) • Do not use indoor sunlamps, tanning beds, or tanning pills • Certain medications such as oral contraceptives, antibiotics, antiinflammatories, antihypertensives, or immunosuppressives may make more sensitive to the sun

22. Braden Skin Scale cont. • Scores range from 6-23 • Lower score means increased risk of skin breakdown • Most facilities use # 18 as a cut off for skin precautions • Assess every shift • Frequent turning • Special mattress • Good Nutrition

23. Braden Pressure Ulcer Risk Score • Sensory Perception • Completely limited (1),very limited (2), slightly limited (3), no impairments (4) • Moisture • Completely moist (1),very moist (2), occasionally moist (3), rarely moist (4) • Activity • Bedfast (1), Chairfast (2), Walks occasionally (3), walks frequently (4) • Mobility • Completely immobile (1),very limited (2), slightly limited (3), no limitations (4) • Nutrition • Very poor (1), probably inadequate (2),adequate (3), excellent (4) • Friction & Shear • Problem (1), potential problem (2), no apparent problem (3)

24. Pressure Ulcers • AKA • Bedsore • Decubitus ulcer • Definition • Localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction • Pressure leads to collapse of blood vessels in area, leading to ischemia

25. Pressure Ulcers • Areas most susceptible: • Occipital skull, pinna or ears, sacrum, ischial tuberosity, tronchanter area of hip, ankles, and heels • Contributing factors: • Impaired mobility/immobility, incontinence, poor nutritional status, altered LOC

26. Pressure Ulcer Stages (Suspected) Deep Tissue Injury Stage I Stage II Stage III Stage IV Unstageable

27. Staging of Pressure Ulcers Stage I Stage ii Stage iii Stage iv Stage V On pg. 122 & 123 are very good pictures and description of each stage of a pressure ulcer please review and familiarize yourself with each.

28. Inspection/Palpation - Nail • Contour • Angle approx 160 degrees. > 180 is abnormal (Clubbing-sign of hypoxia) • Color • Nail translucent, nail bed pink • Capillary refill <2seconds • Consistency • Smooth, regular, thickness uniform. Nail adherent to nail bed. • Nail changes in Elderly • Grow more slowly, lose luster, with longitudinal ridging.

29. Inspection/Palpation - Hair • Quantity • Hair loss • Male pattern baldness, drugs, radiation, hormone levels, stress • Increased hair growth • Hirsutism • Lesions • Separate hair and assess for lesions or pest inhabitants • No lesions or lice noted • Hair changes in elderly • Grey • Axilla & pubic hair decreases due to low testosterone • Women with bristly facial hair due to unopposed testosterone (low estrogen)

30. Summary Early signs Know your terminology How to best assess Prevention, Prevention, Prevention