Guided Lecture Notes

Chapter 14: Assessing Skin, Hair, and Nails

Learning Objective # 1. Describe the structures and functions of the skin, nail and hair.

  • Explain the structure and function of epidermis, dermis and subcutaneous tissue of the skin. (Refer to Figure14.1 and PowerPoint slides 02 - 07)
  • 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.
  • Explain the structure of vellus and terminal hair. (Refer to Figure14.1)
  • Describe the structure of nail. (Refer to Figure14.2)

LearningObjective # 2.Discuss risk factors for skin cancer and METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUSacross cultures and ways to reduce one’s risks.

Discuss the risk factors associated with skin cancer. (Refer to Abnormal Findings 14.5 and PowerPoint slides 8-10)

  • 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
  • Male gender
  • Chemical exposure
  • Human papillomavirus
  • Xerodrem pigmentosum
  • Long-term skin inflammation or injury
  • Alcohol intake; smoking
  • Inadequate niacin in diet
  • Discuss the measures to reduce the risk factors for skin cancer. (Refer to PowerPoint slides 11- 14)
  • 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
  • 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
  • Describe the variations in prevalence of skin color across cultures. (Refer to PowerPoint slide 15)
  • Lowest rates: Asians
  • Highest rates: white Australians
  • Most susceptible are people with pale white, freckled skin and red hair
  • Discuss the risk factors associated with METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS. (Refer to Evidence Based Health Promotion and Disease Prevention 14.1and PowerPoint slides 16 - 18)
  • Assess for hospital-acquired MRSA risk factors:
  • Having an invasive medical device
  • Residing in a long-term care facility
  • 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)
  • Working in the health-care industry
  • Receiving antibiotics within the past 3 to 6 months
  • Young or advanced age
  • Men having sex with men
  • Discuss the measures to reduce the risk factors forMETHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS. (Refer to PowerPoint slide 19)
  • 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.

Learning Objective # 3.Interview a client for an accurate nursing history of the skin, nails and hair.

  • Review collecting subjective data for an accurate nursing history of the skin, nails, and hair
  • History of present health concern (Refer to PowerPoint slide 20)
  • 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
  • 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 (Refer to PowerPoint slide 21)

Learning Objective # 4.Perform a physical assessment of the skin, nails, and hair using the correct techniques.

  • Describe the preparation of the client for assessment of skin, hair and nails. (Refer to PowerPoint slide 22)
  • Ask the client to remove all clothing and jewelry
  • Have the client sit comfortably
  • Ensure privacy
  • Maintain comfortable room temperature
  • List the equipment necessary for performing a skin, hair, and nail assessment. (Refer to PowerPoint slide 23)
  • Gloves
  • Examination light and penlight
  • Magnifying glass
  • Centimeter ruler
  • Wood’s light
  • Examination gown or drape
  • Assessment Tool 14.1. Braden Scale For Predicting Pressure Sore Risk
  • Assessment Tool 14.2. PUSH Scale to Measure Pressure Ulcer Healing
  • Describe the inspection assessments of skin (Refer to PowerPoint slide 24)
  • Note any distinctive odor
  • Generalized color variations (brownness, yellow, redness, pallor, cyanosis, jaundice, erythema, vitiligo)
  • Skin breakdown
  • Primary, secondary, or vascular lesions (note size, shape, location, distribution and configuration). Use Wood’s lamp if fungus is suspected.
  • Primary: arise from normal skin due to irritation or disease
  • Secondary: arise from changes in primary lesions
  • Vascular: reddish-blue lesions are seen with bleeding, venous pressure, aging, liver disease, or pregnancy.
  • Describe the palpation assessments of skin (Refer to PowerPoint slide 25):
  • Lesions
  • Texture (rough or smooth) using palmar surface of three middle fingers
  • Temperature (cool, warm, hot) and moisture (dry, sweaty, oily) using dorsal side of hand
  • Thickness of skin with finger pads
  • Mobility and turgor by pinching up skin over sternum
  • Edema by pressing thumb over feet or ankles
  • Describe the stages of pressure ulcers including risk factors and ways to reduce these risk factors. (Refer to Abnormal Findings 14.1, Pressure Ulcer Stage, and PowerPoint slides 26-28)
  • Risk Factors
  • Perception: inability to perceive pressure
  • Mobility: inability to move self; decreased activity level; unable to reposition
  • Moisture: diaphoresis; incontinences; sweating from climate
  • Nutrition: deficient (especially protein deficit) or excessive (obesity)
  • Friction or shear against surfaces
  • Tissue tolerance decreased: age; vascular incompetence; blood sugar levels of diabetes mellitus; body weight/malnutrition
  • Risk Reduction Tips
  • 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.
  • 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.
  • Describe the assessment of scalp and hair for color, cleanliness, dryness or oiliness, parasites, and lesions. (Refer to PowerPoint slide 29)
  • Explain the assessment of nails for grooming, color, markings, shape, texture, consistency. (Refer to PowerPoint slide 30)
  • List the types of nail abnormalities including risk factors and ways to reduce these risk factors.
  • Risk Factors (Refer to PowerPoint slide 31)
  • Nails in moist environment, especially walking in damp public locales (swimming pools, showers) or continuously wearing closed shoes; excessive perspiration.
  • Nail injury, trauma, or irritation (tight footwear, exercise trauma, artificial nails, excessive hand washing, nail biting).
  • Repeated irritation (especially water, detergents).
  • Immune system disorders such as diabetes mellitus and AIDS or on immunosuppressive medications.
  • Skin conditions such as psoriasis or lichen.
  • Some trades or professions (damp environments or shoe type required).
  • Contagion from one digit to another or one person to another.
  • Possibly family predisposition.

Risk Reduction Tips (Refer to PowerPoint slide 32)

  • 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.
  • Describe the procedure to assess capillary refill. (Refer to Figure 14.15 and Power Point slide 33))
  • Discuss the differences in hair color and texture seen in ethnic groups. (Refer to PowerPoint slide 33)
  • Individuals of black American descent often have very dry scalps and dry, fragile hair.

Learning Objective # 5.Teach a client how to perform a self-assessment of the skin, hair and nails.

  • Review Box 14-1 Self Assessment: How to Examine Your Own Skin (Refer to Box 14.1 Self Assessment: How to Examine Your own Skin and Power Point Slide 34)

Learning Objective # 6.Differentiate between normal and abnormal findings of the skin, hair and nails

  • Review and discuss findings of client’s skin, hair and mails assessment with class peers (Refer to PowerPoint slide 35)
  • Pressure Ulcer Stage (Refer to Abnormal Findings 14.1: Pressure Ulcer Stage and PowerPoint slide 36)
  • Stage One
  • Stage Two
  • Stage Three
  • Stage Four
  • Unstagable
  • Primary Skin Lesions (Refer to Abnormal Findings 14-2: Primary Skin Lesions and PowerPoint slide 37)
  • Macule and Patch
  • Papule and Plaque
  • Nodule and Tumor
  • Vesicle and Bulla
  • Wheal
  • Pustule
  • Cyst
  • Secondary Skin Lesion (Refer to Abnormal Findings 14-3: Secondary Skin Lesionsabd PowerPoint slide 38)
  • Erosion
  • Ulcer
  • Sacr
  • Fissure
  • Vascular Skin Lesions (Refer to Abnormal Findings 14-4: Vascular Skin Lesions and Power Point slide 39)
  • Petechia
  • Ecchymosis
  • Hematoma
  • Cherry Angioma
  • Spider Angioma
  • Telangiectasis
  • Common Nail Disorder (Refer to Abnormal Findings 14-7: Common Nail Disorders and Power Point slide 40)
  • Longitudinal ridging
  • Half and half nails
  • Pitting
  • Koilonychia
  • Yellow nail syndrome
  • Paronychia

Learning Objective # 7.Describe findings frequently seen when assessing the older client’s skin, hair, and nails.

  • Discuss the differences in skin, hair and nail characteristics of elderly people. (Refer to PowerPoint slide 41)
  • Skin
  • Pale
  • Skin lesions
  • Dry
  • Loses turgor
  • Hair: Thinner
  • Nails: Thickened, yellow, brittle

Learning Objective # 8.Analyze data from the interview and physical assessment of the skin, hair and nails to formulate valid nursing diagnoses, collaborative problems, and/or referrals.

  • Discuss as a group the data obtained of a client’s general survey and vital signs risk to formulate valid nursing diagnoses, collaborative problems and/or referrals. (Refer to PowerPoint slide 42)