Chapter 14: Skin, Hair, and Nails Assessment

function of skin

protection, prevents penetration, perception, temperature regulation, identification, communication, wound repair, absorption and excretion, production of vitamin D

older adult considerations

perspiration, flexibility, and mobility decreases

increased risk for pressure injury

paler skin

skin lesions

drier, coarser, and slower hair growth

drier and less turgor

objective assessment key points

◦ Inspect skin color, temperature, moisture, texture.

◦ Check skin integrity.

◦Be alert for skin lesions.

◦ Evaluate hair condition for loss or unusual growth.

◦Note nail bed condition and capillary refill.

inspection of skin

coloration

odors

any color variations

skin integrity

lesions

pallor

Extreme or unnatural paleness

cyanosis

bluish discoloration of the skin

Acanthosis nigricans

thickening and darkening of skin near axillary region, A/w Diabetes Type II and gastric carcinoma

erythema

redness of the skin

palpation of skin

texture: smooth and even

thickness

moisture

temperature

mobility and turgor

edema

assessment of scalp and hair

◦ General color and condition

◦ Cleanliness, dryness or oiliness, parasites, lesions

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

assessment of nails

Inspect for color, shape, contour, thickness

assess nail angle

Note grooming, use of polish, false nails, and nail biting

Palpate texture, consistency, and cap refill

seborrheic keratosis

a benign skin growth that has a waxy or "pasted on" look

cutaneous tag

raised papule with a depressed center

cutaneous horn

hard epidermal projection often seen on senior citizens

cherry angiomas

ruby red papules

risk for pressure injuries

◦ 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

stage 1 pressure injury

non-blanchable erythema of intact skin

stage 2 pressure injury

partial thickness skin loss with exposed dermis

stage 3 pressure injury

full thickness tissue loss with visible fat

stage 4 pressure injury

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.

unstageable pressure injury

obscured full-thickness skin and tissue loss

reducing risk for pressure injuries

inspect skin daily

bathe with mild soap or other agent with warm water

use moisturizers

avoid vigorous massage

careful positioning

incontinence care

macule vs patch

both:

•Small, flat, nonpalpable skin color change

•Skin color may be brown, white, tan, purple, red

macule:

>1cm and circumscribed border

patch: greater than 1cm and irregular border

papule vs plaque

both are raised, defined, any color, solid mass

papule is < 0.5 cm, circumscribed border

plaque is > 0.5 cm

ex of papules

elevated nevi, warts, lichen planus

ex of plaques

psoriasis, eczema, actinic keratoses

nodule vs tumor

both: elevated, solid palpable mass that extends deeper into dermis than papule

nodule: 0.5 to 2 cm and circumscribed

tumors: greater than 1 to 2 cm and do not always have sharp borders

vesicle vs bulla

both: Circumscribed elevated, palpable mass containing serous fluid

vesicle: less than 0.5 cm

bulla: greater than 0.5 cm

ex of vesicle

Herpes simplex/zoster, Varicella (chicken pox), poison ivy and second-degree burn

ex of bulla

Pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo

wheal

Elevated Mass with transient borders

Often irregular

Size and color vary

Caused by movement of serous fluid into the dermis

Does not contain free fluid in a cavity (like a vesicle)

Ex. Urticaria (hives) and insect bites

pustule

Pus-filled vesicle or bulla

Ex. Acne, impetigo, furuncles and carbuncles

cyst

Encapsulated fluid-filled or semisolid mass Located in the subcutaneous tissue or dermis Ex. sebaceous cyst and epidermoid cyst

erosion

Loss of superficial epidermis that does not extend to the dermis. Depressed, moist area.

ulcer

Skin loss extending past epidermis, with necrotic tissue loss. Bleeding and scarring possible.

fissure

Linear crack in the skin that may extend to the dermis and may be painful. Ex. chapped lips or hands and athlete's foot. Interdigital tinea pedis with fissures and maceration is pictured below.

petechia

Round red or purple macule that is 1 to 2 mm in size. Secondary to blood extravasation and associated with bleeding tendencies or emboli to skin

ecchymosis

Round or irregular macular lesion Larger than petechial lesion Color varies and changes: black, yellow, and green hues. Secondary to blood extravasation Associated with trauma and bleeding tendencies.

hematoma

A localized collection of blood creating an elevated ecchymosis Associated with trauma.

spider angioma

Red arteriole lesion with a central body with radiating branches Usually noted on the face, neck, arms, and trunk Rare below the waist Compression of the center of the arteriole completely blanches the lesion. Associated with liver disease, pregnancy, and vitamin B deficiency.

Telangiectasia

Bluish or red lesion with varying shape (spider-like or linear) found on the legs and anterior chest. Does not blanch when pressure is applied.

linear configuration

straight line as in a scratch or streak

ex dermatographism

angular configuration

Circular lesions. An example is tinea corporis.

clustered configuration

Lesions grouped together Ex. is herpes simplex

discrete configuration

Individual and distinct lesions. Ex. multiple nevi.

nummular configuration

Coin-shaped lesions Ex. nummular eczema

confluent configuration

Smaller lesions run together to form larger lesion Ex. tinea versicolor

longitudinal ridging

Parallel ridges running lengthwise. May be seen in the elderly and some young people with no known etiology.

half and half nails

Nails that are half white on the upper proximal half and pink on the distal half. May be seen in chronic renal disease.

pitting nails

seen with psoriasis

Koilonychia

Soft spoon nails with a concave shape that appear scooped out.

From iron deficiency anemia, endocrine or cardiac disease

yellow nail syndrome

Yellow nails grow slow and are curved may be seen in aids and respiratory syndromes

paronychia

infection around the nail

types of skin cancer

Melanoma: African Americans, Asians, and Hispanics are susceptible.

Basal cell carcinoma (BCC): more common in Whites

Squamous cell carcinoma (SCC): more common in darker skin

skin cancer risk factors

sun exposure

moles

fair skin

age

family history

male

HPV

alcohol intake

smoking

inadequate niacin

skin cancer ABCDE

A-asymmetry

B-borders

C-color

D-diameter

E-elevated

MRSA

Type of infection resist to many antibiotics May be hospital-acquired infection (HAI) or community-acquired infection

risk factors for MRSA

• Recent or prolonged hospitalization

• Residence in a long term care facility

• Recent antibiotic therapy

• HIV infection

• Men who have sex with men

• Injection drug use

• Hemodialysis

• Living with many people: jail

• Sharing needles, razors, or sports equipment

• Diabetes

• Swine farming

Braden scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear