Skin, Hair, and Nails

Integumentary System

-it protects deeper tissues

-aids in heat loss/heat retention

-aids in excretion of urea and uric acid

-synthesize vitamin D

Skin

hair

nails

what are the integumentary system?

Mechanical Damage

Chemical Damage

Microbe Damage

Uv Radiation

Thermal Damage

Drying out

it protects deeper tissues, such as?

it is absor

Epidermis

Dermis

Hypodermis (subcutaneous tissue)

Basic Structure of the Skin

Inspect General Skin coloration

Inspect for Color Variation

Check for Skin Integrity

Inspect for lesion

Palpate Skin

Physical Assessment of the Skin

Inspect General Skin Coloration

-check palm to assess overall coloration

Pallor

Cyanosis

Jaundice

Acanthosis Nigricans

Abnormal Discoloration

Pallor

-lack of RBC

-loss of color

-observed in patients with:
Arterial insufficiency

decreased blood supply

Anemia

Cyanosis

-lack of oxygen

-may cause white skin to blue tinged

-locations:

Perioral

nailbed

conjunctival areas

Jaundice

-yellow skin tones

-locations:

Sclera

Oral mucosa

Palms

Soles

Acanthosis Nigricans

-too much insulin in the blood

-roughening and darkening of skin

-associated with endocrine dysfunction

Freckles

Striae

Seborrheic Keratosis

Scar

Mole

Cutaneous Tags

Cutaneous Horns

Cherry Angioma

Common Variation of Skin

Freckles

-flat, small macules of pigment that appear following sun exposure

Seborrheic Keratosis

warts

Mole

-aka nervus

Cutaneous Tags

-yellow papules with depressed center

Cherry Angioma

-small, raised spots in aging

Rashes

Albinism

Erythema

Abnormal skin variations

Albinism

-loss of pigmentation (generalized)

Erythema

-inflammation, allergic reactions

-skin redness and warmth

Pressure Ulcer

Abnormal Finding for Checking of skin integrity?

Pressure Ulcer

it is most preventable skin problem, however if not prevented it could lead to death

Pressure

Shear

Friction

Conditions of Pressure Ulcer

Pressure

-it restrict blood flow

Shear

-tissues move in opposite direction

Friction

-skin rubs against the surface

Perception- perceive pressure

Mobility- ability to move yourself

Moisture-increased moisture

Nutrition

Friction/Shear

Tissue Tolerance- decreased

Assess Risk Factors of Pressure Ulcer

Inspect the Skin (atleast once a day)

Bathe with Mild Soap

Moisturizer with Dry skin

Avoid Vigorous Massage

Positioning (every 2 hours)

Provide balance nutrition

Refer Incontinence

Nursing Intervention of Pressure Ulcer

repositioning every 2 hours (15 mins. if chair)

repositioning schedule

use lifting device (blankets)

avoid elevated head of bed

if you have patient with bed and chair bound?

Braden Scale; Push Tool

tool that helps pressure ulcer in healing

Stage 1

Stage 2

Stage 3

Stage 4

Unstageable

Stages of Pressure Ulcer

Stage 1

-intact skin

-non blanchable redness

-painful

-epidermis infected

Stage 2

-partial thickness loss of dermis

-open/ruptured serum filled bluster

Stage 3

-full thickness tissue loss

-subcutaneous fat is visible

Stage 4

-Full thickness tissue loss

-exposed bone, tendon/ muscles

Unstageable

-full thickness tissue loss

-covered with slough (yellow)and eschar (brown)

Striae

Scars

Mole

Cutaneous Tags

Cutaneous Horn

Cherry Angioma

Common Variation for Lesion

Primary Lesion

what lesion when it is due to irritation and disease

Solid

Fluid-filled

two types of primary lesion

Palpable

non palpable

two types of solid

Palpable

-it is elevated (type of solid)

Non palpable

-it is non elevated (type of solid)

Papule

Plaque

Nodule

Tumor

types of palpable (solid)

Papule

-less than 1 cm (type of Palpable)

Plaque

-greater than 1 cm (type of palpable)

Nodule

-less than 1 to 2 cm (type of palpable)

Tumor

-greater than 2 cm (type of palpable)

Macule

Patch

types of non palpable

Macule

-less than 1 cm (type of non palpable)

Patch

-greater than 1 cm (type of non palpable)

Vesicle

Bullae

Wheal

Pustule

types of Fluid Filled

Vesicle

-it is less than 1 cm

-serous

-chicken pox

(type of fluid filled)

Bullae

-greater than 1 cm; serous (type of fluid filled)

Wheal

-has evanescent effect (absorbs fluid within 48 hrs)

-mosquito bites

(type of fluid filled)

Pustule

-pus filled (type of fluid-filled)

Cyst

-semi solid

Secondary Lesion

-it refers to the changes in primary lesion

Erosion

-shallow depression

Ulcer

-skin loss (dermis)

fissure

-linear crack

Excoriation

-Linear Erosion

Scales

-shedding flakes of gready, keratinized skin tissue

Keloids

-excessive collagen formation in healing

Lichenification

-rough, thickened area, resulted form chronic irritation (form rubbing)

Crust

-dry blood serum

-pus left on skin when pustules burst (kugan)

scar

-flat lesion after healing

Vascular Skin Lesion

type of lesion that refers to bleeding in the blood

Petechia

Ecchymosis

Hematoma

Cherry Angioma

Spider Angioma

Telangiectasis

Vascular Skin Lesion

Petechia

dengue (vascular lesion)

Ecchymosis

-bun’og (vascular)

Hematoma

-bukol (vascular)

Cherry Angioma

-red/ purple; aged related skin alteration (vascular lesion)

Spider Angioma

-associated with liver disease (vascular lesion

Telangiectasis

-venus stur (vascular lesion)

Texture

Thickness

Moisture

Temperature

Mobility/ Turgor

Edema

Palpate Skin for

2mm

1+ (edema)

4mm

2+ (edema)

6mm

3+ (edema)

8mm

4+ (edema)

160 degree

Nails Normal Shape

Beau’s lines

-due to acute illness (abnormal in nails)

Spoon Nails

-due to deficiency anemia (abnormal nails)

Early clubbing

-180 degree with spongy sensation (abnormal Nails)

Late Clubbing

-greater than 180 degree( abnormal in nails)

Pitting

-psoniasis (abnormal nail)

Paronychia

-local infection (abnormal in nail)

Poxia/ anemia

-pale nails

Splinter Hemorrhages

-caused by trauma (in nails)

Onycholysis

-detachment of nailplate from nailbed

Dermatitis

-excessive scaliness (hair)

Tinea Captitis

-pustules hair loss

-contagious fungal disease

folliculitis

-infection of hair follicle

hirsutism

-facial hair on females (imbalance of adrenal hormones)