Skin & Nails

Integumentary System

System including skin and nails for protection and regulation.

Skin Lesions

Changes indicating potential underlying health issues.

Braden Scale

Tool assessing pressure sore risk factors.

Sebum

Oily substance from sebaceous glands for skin protection.

Skin Cancer Statistics

1 in 5 develop skin cancer before age 70.

Health History

Subjective data collection regarding skin health.

Lifestyle Choices

Factors affecting skin health, including diet and occupation.

Diet for Skin Health

Lean proteins and vegetables support skin and nails.

Water Consumption

Hydration aids toxin removal and skin health.

Chemical Absorption

Skin absorbs chemicals, potentially causing disorders.

High-Risk Occupations

Jobs with increased exposure to skin hazards.

Mechanical Trauma

Hobbies causing physical damage to skin and nails.

Nicotine Effects

Accelerates aging and causes discoloration in skin.

Skin Function

Regulates temperature and protects against infection.

Melanocytes

Cells producing pigment in the skin.

Skin Disorders

Over 3000 conditions affecting skin health.

Health Education

Addressing knowledge deficits in skin health.

Skin Color Changes

Indicate possible health issues requiring assessment.

Nail Changes

Alterations in nails can signal health problems.

Occupational Hazards

Risks from chemicals in various job environments.

Skin Assessment

Careful evaluation to identify lesions and rashes.

Smoking Impact

Discolors skin and accelerates wrinkle formation.

Skin Hydration

Essential for maintaining skin elasticity and health.

UV Exposure

Damages skin, causing wrinkles and cancer.

Cumulative Damage

Increases skin cancer risk over time.

Skin Assessment Tools

Includes lighting, ruler, penlight, gloves.

Skin Color Assessment

Evaluates melanocyte content and pigmentation changes.

Baseline Skin Tone

Upper arm skin reflects normal pigmentation.

Turgor

Skin elasticity; assessed by pinching skin.

Skin Tenting

Indicates dehydration if skin remains pinched.

Moisture Assessment

Checks for perspiration in skin folds.

Skin Integrity

Examines for breakdown, color variations, and moles.

Temperature Assessment

Skin should feel warm or slightly cool.

Pressure Points

Areas at risk for skin breakdown.

Diaphoresis

Excessive sweating due to anxiety or heat.

Skin Breakdown

Look for color, elevation, shape, and size.

Exudate Characteristics

Note color, odor, consistency, and amount.

Client Sensation

Assess sensation changes during skin evaluation.

Chemical Exposure

Hobbies may involve exposure to harmful substances.

Medication Reactions

New medications can cause rashes or allergies.

Food Allergies

Common allergens include shellfish and iodine.

Contact Dermatitis

Skin reaction from local exposure to irritants.

Skin Temperature Extremes

Note any unusual temperature variations.

Skin Inspection Areas

Includes mucous membranes, lips, nail beds.

Elderly Turgor Assessment

Best assessed near the clavicle.

Pressure Ulcers

Injuries to skin from prolonged pressure.

Risk Assessment

Evaluation of patient for pressure injury risk.

Sitting Position

Common areas for ulcers: head, shoulders, sacrum.

Side-Lying Position

Common areas for ulcers: ear, elbow, hip.

Back Lying Position

Common areas for ulcers: head, shoulders, buttocks.

Mr. Nicholas Stone

Patient example for Braden Scale assessment.

Score Range

Braden Scale scores from less than 9 to 23.

Low Risk

Braden score of 15-16 indicates low risk.

Moderate Risk

Braden score of 13-14 indicates moderate risk.

High Risk

Braden score of 12 or less indicates high risk.

Sensory Perception

Ability to feel pain or discomfort.

Moisture

Degree of skin exposure to moisture.

Activity

Level of physical activity of the patient.

Mobility

Ability to change body position independently.

Nutrition

Patient's dietary intake adequacy.

Completely Limited

No ability to feel or communicate discomfort.

Very Limited

Responds only to painful stimuli for discomfort.

Slightly Limited

Can respond to commands but not always communicate.

No Impairment

Fully responsive without sensory deficits.

Constantly Moist

Skin always damp, requiring frequent linen changes.

Very Moist

Skin often moist, needing changes at least once per shift.

Occasionally Moist

Skin moist, requiring extra linen change daily.

Rarely Moist

Skin usually dry, routine linen changes sufficient.

Bedfast

Patient confined to bed, no mobility.

Chairfast

Patient can sit but limited mobility.

Walks Occasionally

Patient walks short distances, mostly in bed.

Walks Frequently

Patient walks regularly, at least twice daily.

Completely Immobile

No changes in body position without assistance.

Very Limited Mobility

Occasional slight changes in position with assistance.

Slightly Limited Mobility

Frequent slight changes in position independently.

No Limitation Mobility

Major position changes without any assistance.

Usual Food Intake Pattern

Describes typical eating habits and meal consumption.

Complete Meal

A meal consisting of all food groups.

Protein Servings

Quantifies intake of meat and dairy products.

NPO

Nothing by mouth; no oral intake allowed.

Clear Liquids

Transparent fluids permitted for dietary intake.

IV Nutrition

Intravenous feeding providing essential nutrients.

Braden Risk Assessment

Tool to assess pressure ulcer risk.

Risk Score

Total score indicating risk level for ulcers.

Friction

Resistance encountered during movement against surfaces.

Shear

Force causing skin layers to slide against each other.

Maximum Assistance

Complete help required for movement and repositioning.

Minimum Assistance

Some help needed, but can move independently.

Tube Feeding

Nutritional support delivered via a feeding tube.

TPN Regimen

Total parenteral nutrition providing complete dietary needs.

Nutritional Interventions

Strategies to improve dietary intake and health.

Moisture Management

Controlling skin moisture to prevent breakdown.

Pressure Redistribution Surface

Special mattress designed to alleviate pressure points.

Nutrition Therapy

Dietary strategies aimed at promoting healing.

Skin Cancer

Most common cancer in the U.S.

Melanoma

Less common but highly invasive skin cancer.

5-Year Survival Rate

99% when melanoma is detected early.

Sunburns Risk

Five or more doubles melanoma risk.

ABCDEF Mnemonic

Asymmetry, Border, Color, Diameter, Evolving, Funny looking.

Alopecia Areata

Autoimmune disorder causing patchy hair loss.