NURS 125 Hair, skin and nails

epidermis

outermost layer of the skin where vitamin D synthesis happens

• acts as the body’s first line of defense

• it has 5 layers( stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale→ Come lets get sun burnt)

dermis

supports the epidermis and is made mostly of connective tissue and collagen

• highly vascular

components include:

• blood vessels

• nerves

• lymphatic vessels

• hair follicles

• sweat glands

hair

made of keratin produced by follicles in the dermis except palms and soles of the feet

2 types:

Vellus→ fine, short, light coloured hair you are born with usually(peach fuss)

Terminal→ dark, coarser, found on scalp, brows and postpubertal areas

sweat glands

two types:

• aprocine→ found in specific areas like armpits and groin, they secrete a thicker fluid and are activated by stress and hormones

• Eccrine→ found everywhere and regulate body temperature through sweat production

sebaceous glands

found everywhere except the palms and soles

• secrete sebum to retain moisture and reduce friction

integumentary system

includes the hair, skin, nails, sebaceous and sweat glands that protect the body and help regulate temperature

• skin=body’s largest organ important function is to assist the body in adapting to environmental influences

  • skin is one of the main sites of sensory messaging

constitutive colour

the general colour of a person’s skin

• the areas unaffected by lesions, rashes, skin alterations are “considered their normal”

• can be affected by sun damage, ethnicity, and assessors colour blindness

• it is important to understand this about a patient

Fitzpatrick skin type

way to describe and classify skin types in order to determine potential treatments, risk factors, etc

• more risk factors related to the extremes

• darker skin: higher risk of not absorbing vitamin D

• lightest eye, hair & skin: higher risk for sun damage

• albinism, lesions, hyperpigmentation add another risk factor

risk factor

anything that increases the chance of skin, hair or nail problems

• e.g. excessive sun exposure, poor hygiene, harsh chemicals, smoking

protective factor

anything that helps maintain healthy skin, hair, and nails

• e.g. sunscreen use, proper hydration, gentle skincare, balanced diet

modifiable factor

a factor you can change to improve skin, hair, and nail health

• e.g. medication sthat have effect in the sun, modify usage by not taking it while exposed to the sun

non-modifiable factor

a factor that cannot be changed

• e.g. genetics, age, skin type-Fitzpatrick, hereditary condition

history of present illness(look at textbook for possible questions)

Location

Associated signs or symptoms

Timing

Exposure

Reliving factors

Severity

Nature/quality

Aggravating factors

Patient perspective

Significance to the patient

pallor

paleness

• usually related to lack of iron(anemia) or early lack of perfusion

cyanosis

bluish discoloration

• first indicated in the lips(blueish lips)

clubbing

lack of perfusion to extremities due to cardiovascular concern

erythema

redness

• body’s response to irritation due to heat, abrasions, infections, etc

jaundice

yellowish discolouration of skin and sclera

• skin does not blanch

• physiologic jaundice happens 24 hrs and continues after 72 hrs of birth(for babies)

flushing

temporary redness of the skin

• caused by increased blood flow and increased permeability of the peripheral capillaries

• sometimes caused by excessive alcohol drinking

ecchymosis

bruising

• usually trauma related

petechiae

small reddish to purple macules or papules

• develop in response to hematological issues or regional trauma

primary lesions

arise from previously intact skin

• includes macules, papules, nodules, polyps, vesicles, cysts ,

secondary lesions

arise from primary lesions and include scales, crusts, ulcers, fissures, and scars

what to inspect and palpate for skin lesions/rashes?

• size

• colour

• shape

• texture

• exudate→ fluid that leaks out of blood vessels into nearby tissues

• tenderness

• configuration

• location and distribution

• vascular=check for pulsations and blanching

configuration

the shape of single lesions and the arrangement of a group of regions

• e.g. linear, annular, target(bull’s eye)

• shingles configuration lies against the dermatomes

macules

flat, discolored spots on the skin usually <1 cm

e.g. freckles(ephelides) , flat moles

papules

lesion with layer of skin on top of it

• small raised, solid bumps, usually <1 cm

• e.g. warts, insect bites

pustules

small, pus filled bumps usually <1 cm

• show an elevation of the epidermis

• leak bacteria but in thicker areas of the skin

• e.g. acne, impetigo

plaques

raised, flat-topped lesions >1 cm

e.g. psoriasis patches

scale

thin, flaky pieces of skin that shed from the outer layer of the skin, often seen in conditions like psoriasis or eczema.

purpura

purple or red spots on the skin due to bleeding underneath

• blood is trapped in cells underneath the skin

telangiectasia

dilated small blood vessels near the surface of the skin, often appearing as red or purple lines

lesion colours

• red

• orange

• yellow

• violet(vascular lesions)

• black→ melanocytic

• shades of blue, silver, and gray

location and distribution of the lesions

can tell us the cause or source of the problem

• describe number of lesions(single or multiple), are they in a pattern or random?

• symmetric or asymmetric

• what body part→ sun exposed or sun protected?

ABCDE’s of hyperpigmented lesions

A: Asymmetry→ does one half look life the other?

• is it round symmetric lesion

• if you draw a line through the middle the halves of the melanomas won’t match in size

B: Border→ is the border, ragged, notched uneven or crusty?

C: Colour→ does the mole have variety of shapes or different colours

• healthy moles are uniform in colour

D: Diameter→ is the lesion larger than 6mm?(larger than a pencil eraser)

E: Evolving→ has the lesion changed in size, shape, or colour over time?

• bleeding, scabs, tenderness point to danger also

pressure injuries

1. pressure of bony prominence against surface for long period of time

   • can be as short as 15 minutes

2. friction→ e.g. feet rubbing against wheelchair handle

3. shear→ e.g. thinned skin person ripping skin with fingernail

Braden scale for risk assessment

looks at the risk for developing pressure sores

acral lentiginous melanoma(ALM)

most common melanoma found in people of colour

skin turgor

measure of skin elasticity

how to assess: pinch the skin and lift off the body→ watch how long it takes to return to normal

• less than or equal to 3 secs is normal

• can be affected by hydration

• decreases as a result of the thinning of the dermis and reduced elastin production

inspection of hair

colour, infestations, hygiene, quantity

• distribution→ affected by age, gender, or genetics(puberty brings onset of pubic hair)

• pattern of loss

• colour→ some illness affect ahir colour

• texture→ any change in texture dry, coarse, fine, silky

• note areas of absent hair(alopecia) or lesions

• hair shaft should be smooth, shiny, of even consistency, without evidence of breakage

palpation of hair

lightly palpate the texture, moisture, hygiene

• scalp should be mobile and non-tender

• hair should be smooth

• not excessive hair loss and then assess for absence or presence of hair bulb

inspection of nails

assess for colour, shape, thickness, and consistency

• have patient place the fingernails of both index fingers together to assess the nail angle(heart with finger)→ diamond shaped opening should be visible

palpation of nails

nails are smooth, non-tender

• lateral and proximal folds are non-tender

• assess capillary refill: apply pressure to the nail bed to cause blanching (change to white/lighter colour)

  • less than 3 secs

  • > 4 secs indicates severe dehydration or insufficient vascular supply

capillary refill

determines if there is good prefusion

• to assess: apply pressure to the nail bed to cause blanching (change to white/lighter colour)

  • less than 3 secs

  • > 4 secs indicates severe dehydration or insufficient vascular supply

nail clubbing

indicates chronic hypoxia or peripheral vascular disease(extent of clubbing shows extent of illness)'

• when the angle of the nail to the finger is more than 160 degrees

• fingernails do not touch when put together(heart with fingers)

• nails beds are spongy

Beaus lines

results from slowed or halted nail growth in response to illness, physical trauma, or poisoning

spooning nails

Nails that curve inward, like a spoon

• can indicate health issues like iron deficiency anemia or trauma, and may increase the risk of infection

red flags

pressure injury→ we use Braden Scale for risk assessment

• acute dehydration

• cyanosis

• melanoma

• acute trauma and burns

inspection

colour: use natural or halogen lamp(not fluorescent) and assess uniformity

• sun exposed areas vs not exposed

• assess mucous membranes and conjunctiva

hygiene→ odour, infection

Lesions/ rashes/swelling/erythema/discharge→ just because it is in one spot does not mean it is not anywhere else

palpation of skin

temperature, moisture, thickness, texture, turgor

• temperature→ using dorsal surface of hands

• moisture→ using palmar surface of fingers and hands, a to assess moisture and texture

• thickness

• turgor→ skin turgor test

nodules

solid, raised skin lesions, usually > 1 cm and deeper than papules

e.g. lipomas, cysts

vesicles

small, clear skin coloured lesion with water but no erythema- fluid filled blisters

• usually <1 cm

• e.g. chickenpox, herpes

urticara(hives)

raised, red, itchy, welts of varying sizes

• usual appear in clusters

• usually an allergic reactioj

bullae

large fluid-filled blisters usually

• > 1 cm in diameter

• can be caused by burns, contact dermatitis, or infections