Skin, Hair and Nails

What is subjective assessment?

What the patient tells you

What are the main areas of focus in a subjective assessment? (7)

• Issues

• Changes

• Past medical history

• Family history

• Medications

• Allergies

• Lifestyle

What acronym helps us remember all the areas to cover when discussing the issues of a patient?

OLDCARTS

What does OLDCARTS stand for in a subjective assessment?

• Onset

• Location

• Duration

• Characteristics

• Aggravating/Alleviating Factors

• Related Symptoms

• Treatments by patient

• Severity

In OLDCARTS, what does onset mean?

What came on (when it started)

In OLDCARTS, what does location mean?

Where the issue is located

In OLDCARTS, what does duration mean?

How long the issue has been present

In OLDCARTS, what does Characteristics mean?

Qualities of the issue

In OLDCARTS, what does Aggravating/Alleviating mean?

What makes it better or worse and when is it better or worse

In OLDCARTS, what does related symptoms mean?

What else is happening with this issue

In OLDCARTS, what does treatment by patient mean?

What the patient has tried at home (ointments/medications/etc)

In OLDCARTS, what does severity mean?

Pain level and if it has been better or worse

What is an objective assessment?

What the nurse examines

What should always be done first in an objective assessment?

General survey before systematic approach

What order is used to inspect the skin?

Head to toe approach

Which areas should be especially focused on during a skin exam?

Areas prone to skin breakdown, eyes, lips, and inside the mouth

What does the ABCDE format stand for when inspecting lesions to see if they are malignant?

• Asymmetry

• Border irregularity

• Color variety

• Diameter greater than 6 cm

• Evolution over time

What do you check for when palpating the skin? (3)

• Temperature

• Turgor

• Edema

What is a normal skin turgor result?

Less than 4 seconds

Where is turgor assessed in adults vs older adults?

Adults should be on top of the hand, older adults should be on the medial thigh

What do you note for when assessing hair?

• Texture

• Hygiene

• Lesions

• Nits

Which hidden areas should not be forgotten during a hair inspection?

Behind the ears and at the base of the scalp

Why are hair styles relevant in a hair assessment?

They can hide or contribute to scalp/skin issues

What is the order of assessment for nails?

• Inspect

• Palpate fingernails

• Palpate toenails

What is a normal capillary refill time?

Less than 2 seconds

What is the normal nail angle?

Less than 160 degrees

What does a nail angle of greater than 160 indicate?

Clubbing which happens due to poor perfusion (usually due to chronic respiratory conditions like COPD)

What are the 5 main types of data collection tests?

• Complete Blood Count (CBC)

• Basic Metabolic Panel (BMP)

• Cultures

• Allergy Testing

• Biopsy

What does a CBC tell you about?

• RBC count

• Hemoglobin

• Hematocrit

• RBC morphology

• Platelet count

• Platelet size

• WBC count

What does hemoglobin measure?

How well oxygen is being carried by proteins through the blood

Is hemoglobin higher in men or women?

Men

What does hematocrit measure?

The percentage of RBCs in the blood (Volume of RBCs/Volume of blood)

Is hematocrit higher in men or women?

Men

What does RBC morphology tell you?

The shape of RBCs

What does WBC count tell you?

Infection status (higher WBCs means more infection)

What is a CBC with differential?

A CBC that breaks down the different types of WBCs specifically (helps know what stage of infection the patient is in)

What does a BMP tell you about?

• Sodium levels

• Chloride levels

• Potassium levels

• BUN

• Creatinine levels

• GFR

• Calcium levels

• Glucose levels

What do BUN, creatinine and GFR tell you?

How good the patients kidney function is

What does glucose level indicate?

Blood sugar status

What is a wound culture?

A swab of a wound sent to the lab to grow and identify organisms

What is allergy skin testing used for?

To detect allergies by observing skin reaction to certain substances

What is a biopsy?

A sample of tissue sent to the lab to understand more about a lesion or condition

What are examples of biopsy types?

• Bone marrow biopsy

• Excisional biopsy

What are the three phases of wound healing?

• Inflammatory

• Proliferative

• Remodeling

When does the inflammatory phase begin and how long does it last?

Within 30 minutes of injury and lasts 2-3 days

What occurs in the inflammatory phase?

• Vasoconstriction

• Platelet aggregation

• Inflammatory reactions

• Swelling

• Erythema

When does the proliferative phase begin and how long does it last?

Begins at the end of the inflammatory phase and may last up to 4 weeks

What occurs in the proliferative phase?

Fibroblasts deposit collagen and growth factors and the wound beds show granulation (formation of new, soft, red tissue)

When does the remodeling phase begin and how long can it last?

Begins right after proliferative phase and may last as long as 2 years

What occurs in the remodeling phase?

Rapid collagen replaced by mature collagen, increasing tensile strength of the wound

What are 9 common types of primary skin findings?

• Macule

• Papule

• Patch

• Vesicle

• Bulla

• Plaque

• Wheal

• Cyst

• Pustule

What is a macule?

A flat, circumscribed, discoloration on the skin the is LESS than 1 cm

What is a patch?

Flat, circumscribed, discoloration that is GREATER than 1 cm

What is a papule?

A raised, defined, solid bump under the skin

What is a vesicle?

A small, fluid filled sac or blister that is LESS than 1 cm

What is a bulla?

A fluid filled sac that is GREATER than 1 cm

What is a plaque?

A raised, flat topped lesion that is greater than 1 cm

What is a wheal?

A raised, irregular, transient lesion due to edema

What is a cyst?

A sac filled with fluid or semi solid material

What is cystic acne?

Inflamed, deep, pus filled cysts on the skin caused by blacked pored and infection

What is a pustule?

Small, raised, pus filled lesion

What is a keloid?

Overgrowth of fibrous tissue forming an enlarged scar

What is a scar?

Fibrous tissue replacing normal skin after injury or surgery

What is atrophy of the skin?

Thinning or loss of skin, sometimes from aging or sun exposure

What is excoriation?

A lesion from scratching or excessive rubbing of the skin

What are the 7 main patterns of lesion distribution?

• Asymmetrical

• Symmetrical

• Bilateral

• Diffuse

• Generalized

• Localized

• Grouped

What does asymmetrical lesion distribution mean?

Lesions appear only on one side

What does symmetrical lesion distribution mean?

Lesions appear only both sides

What does bilateral lesion distribution mean?

Lesions are EQUALLY distributed on both sides

What does diffuse lesion distribution mean?

Lesions Are widely spread across an area without a clear pattern

What does generalized lesion distribution mean?

Lesions cover one specific large body area

What does localized lesion distribution mean?

Lesions are confined to one distinct area

What does grouped lesion distribution mean?

Multiple lesions or wounds clustered in a pattern

Why are cultural considerations important in skin assessment?

Some findings may appear abnormal but are benign and require no medical intervention

What are common cultural/benign skin findings?

• Cafe au lait spots

• Congenital dermal melanocytosis

• Stork bite

• Traction alopecia

• Pseudofolliculitis barbae

• Cupping

• Coining

• Skin tone variations

What are cafe au lait spots?

Hyperpigmented lesions that range from light to dark brown, do not go away, but may fade or change shape over time

What is congenital dermal melanocytosis? (Mongolian spots)

Flat, gray-blue patches common in darker skinned newborns, often on the lower back, butt, or legs. Caused by melanocytes trapped deep in skin layers. May resemble bruises

What are stork bites? (Nevus simplex)

Capillary malformations found on eyelids, between eyebrows or nape of neck. Usually fade within 1-2 years of life

What is pseudofolliculitis barbae?

”Razor bumps” - follicularly based erythematous and hyperpigmented papules/pustules. Usually sterile but can become infected. Can lead to hyperpigmentations, hypertrophic scars, or keloids. Treated with topical steroids, benzoyl peroxide, topical antibiotics, and rest form shaving or tight hairstyles

What is cupping?

A cultural therapy where heated cups are placed on the skin, leaving circular erythematous or bruised marks

What is coining?

A cultural practice where a coin in rubbed on the skin, leaving linear erythematous marks or petechia

Why should skin tone be considered in assessments?

Certain conditions may appear differently depending on skin pigmentation, and benign findings may mimic pathology in darker or lighter skin tones

What is the Branden Scale used for?

To determine a patients risk of skin breakdown

What are the 6 criteria of the Branden Scale?

• Sensory perception

• Moisture

• Activity

• Mobility

• Nutrition

• Friction and shear

How is the Branden Scale scored?

Each category is 1-4 (except friction and shear which is 1-3), max score is 23 (higher is better)

What range of score on the Branden Scale indicates no risk?

19-23

What range of score on the Brandon Scale indicates low/mild risk?

15-18

What range of score on the Brandon Scale indicates moderate risk?

13-14

What range on the Brandon Scale indicates high risk?

10-12

What range on the Brandon Scale indicates Severe risk?

9 or below

What is oxygenation?

The process of providing oxygen to cells through adequate gas exchange

What is hypoxemia?

Abnormally low oxygen in the blood (measured through a blood gas)

What is hypoxia?

Insufficient oxygen reaching the tissues (assessed with pulse ox or appearance)

What is clubbing of the nails a sign of?

Chronic hypoxemia due to poor perfusion

Is clubbing reversible and does it require immediate contact to the doctor?

It is irreversible and occurs over a long period of time so it is not something that needs immediate attention, just something to note

Why is cyanosis?

Late sign of hypoxia presented through a color change in the skin

How does cyanosis present in different skin tones?

Lighter skin looks blue and darker skin looks gray or green

What actions can help hypoxia?

• Elevate the head of the bed

• Give oxygen

• Breathing treatments

• Treat underlying cause

What is perfusion?

Process of the heart transporting blood throughout the body

What is ischemia?

Decreased blood supply