Health assessment: skin hair and nails questions

Biological (Cultural Behavior and Genetics) Variation of Skin, Hair, & Nails

- Sweat gland differences (People in tropics have better functioning glands)

- Skin color in relation to location (equator)

- Skin cancer differences

- Fair skin allows for more absorption of vitamin D, highest skin cancer risk

Some conditions more common with darker skin color

- Post-inflammatory hyperpigmentation

- vitiligo, pityriasis alba

- dry or "ashy" skin

- dermatosis papulosa nigra (flesh moles)

- Keloids

- keloid-like acne on the neck (from shaving)

- hair loss

Older adult Skin

- Skin becomes pale due to decreased melanin production and decreased dermal vascularity.

- May have skin lesions: seborrheic or senile keratosis, senile lentigines, cherry angiomas, purpura, cutaneous tags and horns

- Skin may feel drier due to decrease in sebum production.

- Skin loses turgor due to decrease in elasticity and collagen fibers; sagging or wrinkled skin appears in facial, breast, and scrotal areas.

- Increased risk for pressure injury

Older adult Other

- Perspiration decreases with aging due to decreased sweat gland activity.

- Decreased flexibility and mobility may impair the ability of some elderly clients to maintain proper hygiene practices.

- Hair feels coarser and drier, also thins with slower growth.

- Pubic, axillary, and body hair decreases; alopecia; terminal hair growth on chin of women.

- Nails may appear thickened, yellow, and brittle

Subjective

- History of present health concern (Skin, Hair and nails), Personal health history, Family history

- Lifestyle and health problems

- Exposure to sun or chemicals

- Daily care of skin, hair, and nails

- Usual diet and exercise patterns

Preparing the client

- Ask the client to remove all clothing and jewelry and put on examination gown.

- Should also remove nail enamel, artificial nails, wigs, toupees, or hairpieces.

- Have the client sit comfortably and ensure privacy.

- Maintain a comfortable room temperature and adequate light.

- Explain what will be doing, answering any questions.

- Be aware of possible cultural concerns.

Equipment

Gloves, Examination light and penlight, Mirror for client's self-examination of skin, Magnifying glass, Centimeter ruler, Wood light, Braden Scale, PUSH Tool

Key points to remember during examination

- Inspect skin color, temperature, moisture, texture.

- Check skin integrity.

- Be alert for skin lesions.

- Evaluate hair condition for loss or unusual growth (apart from normal age or development)

- Note nail bed condition and capillary refill.

Inspection

- General skin coloration

- Note any odors

- Color variations: Pallor, Cyanosis, Jaundice, acanthosis nigricans, erythema,

- Skin integrity and Lesions

Palpation

Texture, Thickness, Moisture, Temperature, Mobility and turgor, Edema

Scalp and Hair

- Inspection and palpation

- General color and condition

- Cleanliness, dryness or oiliness, parasites, lesions

- Amount and distribution of scalp, body, axillae, pubic hair

Nails

- Inspection: Nail grooming and cleanliness, Color and markings, Shape of nails

- Palpation: Texture, Consistency, Capillary refill

Common variations

Freckles, Vitiligo, Striae, Keratosis, Moles, Cutaneous tag, Cutaneous horn, Cherry angiomas

Pressure ulcer risk factors

- Prolonged pressure to body (bony prominences)

- Decreased/absent perception or sensation

- Decreased/absent mobility

- Increased moisture

- Increased/decreased nutrition

- Friction or shearing forces

- Fragile tissues and skin due to age, vascular incompetence, diabetes mellitus, body weight (over or under)

Pressure ulcer stages

- Stage 1: non-blanchable redness, skin still intact, localized area

- Stage 2: partial thickness loss, some exposed dermis, wound bed still viable with red skin, no fat or adipose tissue seen, blisters

- Stage 3: full thickness loss, w/o undermining, see fat (muscle, tissue, ligaments not seen)

- Stage 4: 3+ undermining, see tendon, muscle

- Unstageable: full extent of the damage and depth is obscured by a layer of dead tissue, like slough or eschar

Risk reduction

- Inspect: Inspect the skin at least daily and more often if at higher risk using risk assessment tools (such as Braden Scale or PUSH tool) and keep flowchart to document.

- Bathe: Bathe with mild soap or other agent; limit friction; use warm, not hot, water; set bath schedule that is individualized.

- Skin: for dry skin use moisturizers; avoid low humidity and cold air.

- Avoid: Avoid vigorous massage

Risk reduction steps

1. Use careful positioning, turning, and transferring techniques to avoid shear and friction or prolonged pressure on any point.

2. Refer nutritional supplementation needs to primary care provider or dietitian, especially if protein deficient.

3. Refer incontinence condition to primary care provider.

4. Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products.

For Bed or Chair Bound clients

- Self-reposition every 15 minutes (chair) or 2 hours (bed)

- Use a repositioning schedule.

- Use a pressure mattress or chair cushion, or sheepskin in bed or chair.

- Use lifting devices as directed to reduce shear (trapeze bar for client; lifts for family, if necessary).

- Use positioning with pillows or wedges to avoid bony prominence contact with surfaces and to maintain body alignment

- For those who are bed bound, avoid elevating the head of bed beyond 30 degrees, except for brief periods.

- Provide structured teaching for clients, family, and caregivers as necessary.

Nail irregularities

- Longitudinal ridges, Half and half: white upper, pink distal (chronic renal disease), Pitting, Koilonychia, Yellow nail syndrome, Paronychia

Skin Cancer

- Most common type of cancer

- Three types: Melanoma, Basal cell carcinoma (BCC), Squamous cell carcinoma (SCC)

- Non Melanotic skin cancers and Malignant melanoma

Skin cancer risk factors

- Sun and chemical exposure

- Nonsolar sources of UVR

- Family history and genetic susceptibility, gender (male), and age

- Fair skin that burns and freckles easily; light hair, pigmentation irregularities, and Moles

- Long-term skin inflammation injury

- Alcohol intake, smoking, diet (inadequate niacin in diet), and medical therapies

- Depressed immune system and conditions:

- Human papillomavirus, Xeroderma pigmentosum, Bowen disease, Actinic keratosis

Education

- Reduce skin exposure

- Use sunscreen when sun exposure is anticipated

- Wear long-sleeve shirts and wide-brimmed hats

- Avoid sunburns

- Wear sunglasses that wrap around

- Understand link between sun exposure and skin cancer and accumulating effects of sun exposure on developing cancers

- Examine skin for suspected lesions

ABCDE Client education

- Ensure that diet is adequate in vitamin B3 (niacin).

- Examine the skin for suspected lesions using the ABCDE mnemonic to assess suspicious lesions:

- Asymmetry, borders (irregular), color (change), diameter, elevated

Exam

1. Examine the body front and back in the mirror, then the right and left sides, with the arms raised.

2. Bend the elbows, looking carefully at the forearms, back of the upper arms, and palms

3. Next, look at the back of the legs and feet, the spaces between the toes, and the soles of the feet.

4. Examine the back of the neck and the scalp with a handheld mirror. Part the hair to lift.

5. Finally, check the back and buttocks with a hand mirror.

Improved results with MRSA bundle approach

- Nasal swabbing and testing for MRSA colonization

- Contact precautions

- Hand hygiene

- Institutional culture of infection control for all personnel in contact with clients

HAI MRSA risk factors

- Highest risk factor: impaired skin integrity

- Assess for hospital-acquired MRSA risk factors:

- Having an invasive medical device

- Residing in a long-term care facility

- Presence of an MRSA-positive person in the facility

Community risk factors

- Participating in contact sports

- Sharing personal items such as towels or razors

- Suppression of immune system function

- Residing in unsanitary or crowded living conditions

- Working in health care industry

- Receiving antibiotics in past 3 to 6 months

- Young or advanced age

- Men having sex with men

- Hemodialysis

Client education

- 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.

- Wash clothes, sheets, towels, razors, and other personal items before and after use.

- Clean hands often.