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Tommie Lillpop Chapters 8, 26,27,35 Test 2 Study Guide Chapter 26 Assessment of Skin, Hair, and Nails

ANATOMY AND PHYSIOLOGY REVIEW Subcutaneous Fat (adipose tissue): serves as insulator, provides padding, is the innermost layer of skin Dermis (Corium): layer above the fat layer, contains elastin, contains no cells, collagen is the main component, rich in sensory nerves Ground substance: a protein lubricant that surrounds the dermal cells and fibers and contributes to the skins normal suppleness and turgor Epidermis: outermost layer of skin, does not have a separate blood supply, synthesizes vitamin D, produces melanin Dermal papillae: finger-like projections of dermal tissue that anchors the epidermis and the dermis together Rete pegs: fingers of the epidermal tissue that projects into the dermis Malpighian layers: older keratinocytes that are pushed upward to form the stratified layers of epithelium Stratum corneum: horny layer, outermost skin layer, not living, shed from skin Keratin: protein produced by keratinocytes, makes horny layer waterproof Melanocytes: pigment producing cells found at the basement membrane, give color to the skin, *darker skin tones are not caused by increased numbers of melanocytes; rather, the size of the pigment graunules (melanin) contained in each cell determines the color. *Purpose of melanin is to protect the skin from UV damage.

STRUCTURES OF SKIN APENDAGES Hair: a thick protective pelt worn by most mammals, is mainly a cosmetic feature for modern humans

Hair follicles are located in the dermal layer of the skin but are actually extensions of the epidermal layer. Nails: cosmetic factor, serve as useful tools for grasping and scraping. Lunula: white, crescent-shaped portion of the nail at the lower end of the nail plate Cuticle: a layer of keratin at the nail fold attaches the nail place to the soft tissue of the nail fold. Sebaceous Glands: distributed over the entire skin surface except for the palms of the hands and the soles of the feel, most are connected to hair follicles. Sweat Glands, 2 types Eccrine: arise from the epithelial cells, found over entire body, not associated with hair follicles, odorless colorless isotonic secretions are important for temp regulation. Lose 10-12 liters of fluid a day Aprocrine: in direct contact with hair follicle, found mostly in axillae, nipple areolae, and perineal and periumbilical body areas. Interaction with skin bacteria causes distinctive odor ASSESSMENT METHODS Obtain History Demograpic data includes age, race, occupation, and hobbies, or recreational activities Race and Nationality can be important because some skin variations are normal for some but not for others. Info about occupation and hobbies can provide clues to chronic skin exposure to chemicals, irritants, abrasive substances, and other environmental factors that can contribute to skin problems. Socioeconomic status can help identify environmental factors that can contribute to skin disease. Skin problems related to poor hygiene are common. Drug use is important because all OTC, recreational drugs, or herbal remedies can cause allergic skin reactions Also ask about new personal care products because they often can lead to allergic reactions. Nutrition History Hydration status influences overall skin health, and the skin can reflect hydration status. Decreased fluid intake can lead to dry skin, loose skin manifested my tenting upon pinching. Fluid overload with edema can stretch the skin, masking wrinkles and allowing the formation of pits when pressure is applied.

Family History and Genetic Risk Psoriasis, skin cancer, keloid formation, and eczema have a hereditary predisposition Identify communicable diseases that could be transferred among family member (ringworm, scabies)

SKIN ASSESSMENT Primary Lesions: an initial reaction to a problem that alters one of the structural components of the skin Secondary Lesions: changes in the appearance of the primary lesion Pruritus: itching Acute dermatitis often occurs as primary vesicles with associated itching. Secondary lesions in the form of crusts occur as the patient scratches, the vesicles are opened, and the exudate dries. Lichenified: thickened Assess each lesion for the following ABCD features that are associated with skin cancer: Asymmetry Border irregularity Color variation within one lesion Diameter greater than 6mm A patient who has a lesion with one or more of the ABCD features should be evaluated by a dermatologist or surgeon. Teach patients these signs, and encourage them to perform total skin exams on a monthly basis. Edema causes skin to appear shiny, taut, and paler than uninvolved skin. Moisture Content is assessed by noting the thickness and consistency of secretions. Excess moisture can cause skin breakdown. Dry skin can be especially marked in areas of poor circulation, such as the legs and feet Normal Vascular Markings include birthmarks, cherry angiomas, spider angiomas, and venous stars. Abnormal vascular markings: Purpuric Lesions: bleeding under the skin red to purple to brownish yellow

Petechiae: small, reddish purple lesion that do not fade or blanch when pressure is applied, often appear in pts with chronic venous insufficiency Ecchymoses: bruises, are larger areas of hemorrhage, low platelet count and blood thinning durgs can lead to excessive bruising Integrity of skin is assessed by examining areas with actual breaks or open areas. Cleanliness of the skin is evaluated to gain info about self-care needs. Tattoos and Piercings can cause or mask skin problems and should be carefully examined. PALPATION Use palpation to gather additional info about skin lesions, moisture, temperature, texture, and turgor because inspection alone can be misleading. Macular: flat Papular: raised Turgor: indicates the amount of skin elasticity Assess skin turgor of older adult on the forehead or chest because of the normal loss of elasticity associated with aging, assessment of tugor can be difficult. HAIR ASSESSMENT During the skin assessment, inspect and palpate the hair for cleanliness, distribution, quantity, and quality. How well the hair is groomed, including the cleanliness of areas of thicker hair growth, can confirm, information already gathered about the pts social history and health care needs. Dandruff: a collection of patchy or diffuse white or gray scales on the surface of the scalp, is common. It is a problem on excessive oil production, not dry scalp! If severe dandruff is not treated, hair loss can occur. Although gradual hair loss with aging is normal, sudden asymmetrical or patchy hair loss at any age is a concern. Body hair loss, especially on the feet or lower legs, may occur as a result of circulatory problems and decreased blood flow. Hirsutism: excessive growth of body hair or hair growth in abnormal body areas. NAIL ASSESSMENT Dystrophic (abnormal) nails may occur with a serious systemic illness or local skin disease involving the epidermal keratinocytes. Assess nails for color, shape, thickness, texture, and the presence of lesions.

Color of the nail plate depends on nail thickness and transparency, amount of red blood cells, arterial blood flow, and pigment deposits. Regardless of skin color, the healthy nail blanches (lightens) with pressure. To differentiate between color changes from the underlying vascular supply and those resulting from pigment deposition, blanch the nail bed to see whether the color changes with pressure. Do this by gently squeezing the end of the finger or toe, exerting downward pressure. Color caused by vascular alterations changes as pressure is applied and returns to the original state when pressure is released. Color caused by pigment deposition remains unchanged. Onychomycosis: fungal infection of the toenail, usually in older adults, that causes the toenail to look headed up.This can cause the nail to become very brittle and split. Onycholysis: separation of the nail plate from the nail bed creates an air pocket beneath the nail plate. First appears as a grayish white opacity, but may change color from dirt and keratin collecting in the pocket and produces a foul odor. Acute Paronychia: inflammation of the skin around the nail

ASSESSING SKIN FOR PATIENTS WITH DARK SKIN CYANOSIS examine lips and tongue for gray color examine nail beds, palms soles for blue tinge examine conjunctiva for pallor. INFLAMMATION Compare affected area with unaffected area for increased warmth Examine the skin of the affected area to determine whether it is shiny or taut or pits with pressure Compare the skin color of affected area with the same area of the opposite side of the body Palpate the affected area and compare it with unaffected area to determine whether texture is different (affected area may feel hard or woody) JAUNDICE Check for yellow tinge to oral mucous membranes, especially hard palate

Examine sclera nearest to the iris rather than the corners of the eye BLEEDING Compare the affected area with the same area of the unaffected body side for swelling or skin darkening If the pt had thrombocytopenia, petechiae may be present on the oral mucosa or conjunctiva

PSYCHOSOCIAL ASSESSMENT Assess body language for clues indicating a disturbance in self appearance. Avoidance of eye contact, or garments to cover affected areas Skin changed linked to poor hygiene is often associated with low economic status and those with reduced cognitive function. In older adults with poor hygiene evaluate any physical limitations. DIAGNOSTIC ASSESSMENT Cultures for fungal infection: use a tongue blade, gently scrape scales from the skin lesions into a clean container and send to lab for culture. Collect fingernail clippings and hair in a similar manner. Specimen is treated with potassium hydroxide (KOH) because of the delay of culture results. A positive KOH test often eliminates the need for a culture Cultures for bacterial infection: obtained from primary lesion if possible. Express material from the lesion, collect it with Q-tip, and place in culture medium specified by lab. Unroofing: for intact lesions, lifting or puncturing the outer surface, may be needed using a sterile small-gauge needle before the material can be expressed. If crusts are present, remove with saline and swab underlying exudate. Biopsies of deep bacterial infections like cellulitis the physician or advanced practice nurse can inject nonbacteriostatic saline deep into the tissue and then aspirate it back; the aspirate is sent for culture. Cultures for viral infection are indicated if a herpes virus infection is suspected. Use a Qtip to obtain vesicle fluid, place in viral culture tube, and PLACE ON ICE, transport to lab ASAP. Punch biopsy is most common, uses a small circular, cutting instrument punch (2-6mm) Inject with local anesthetic, and then a small plug is removed Shave biopsies remove only the portion of the skin elevated above the surrounding tissue when injected with local anesthetic.

Excisional biopsy is rarely used for skin problems. Involve more discomfort and is sutured closed afterwards. Patient Prep: explain what to expect, emphasize that it is a minor procedure, scarring is minimal with punch and shave biopsies, with excisional scar will be similar to a healed surgical incision Procedure: Sterile Field, most uncomfortable is during injection of anesthetic, which produced burning sensation, bleeding can be controlled by applying a topical hemostatic agent or with suturing Follow up care: after bleeding is under control and any suture have been placed, site is covered with bandage or dry gauze. Instruct patient to keep dressing dry and in place for at least 8 hours. Teach to clean site daily after removal of dressing. Tap water or saline can be used to remove dried blood or crust. Instruct pt to report any redness or excessive drainage. If sutures applied, removed in 7-10 days. Woods Light Exam: black light used to identify infection (will appear blue-green or red) Diascopy: noninvasive, painless, eliminates erythema caused by increased blood flow, thereby easing inspection, glass slide or lens is placed down over area to be examined, blanching the skin, and revealing shape of lesions.