skin & nails
Integumentary System
The largest organ in the body.
Approximately 20 square feet of surface area in adults.
Acts as a body guard, protecting the underlying structures.
Composed of three main layers:
Epidermis: The outermost layer.
Dermis: The deeper layer.
Subcutaneous: The layer underneath the dermis.
Structure and Function of Skin
Functions of the skin:
Waterproof, protective, and adaptive.
Provides protection from environmental hazards including pathogens, chemicals, and physical injuries.
Prevents penetration of harmful substances.
Responsible for sensory perception (touch, pain, temperature).
Aids in temperature regulation through perspiration and blood flow.
Plays a role in identification and communication.
Involved in wound repair processes.
Involved in absorption and excretion of various substances.
Production of vitamin D through exposure to sunlight.
Epidermal Appendages
Hair:
Has cosmetic and psychological importance.
Composed primarily of keratin.
Types of hair: Vellus (fine, light-colored) and Terminal (thick, dark).
Sebaceous Glands:
Produce sebum, an oily substance that lubricates skin and hair.
Sweat Glands: There are two types:
Eccrine glands: Located all over the body and regulate temperature.
Apocrine glands: Associated with hair follicles and found in specific areas like the underarms.
Nails:
Hard plates made of keratin.
Components include the lunula (the visible part of the nail root) and the cuticle.
Older Adults and Skin Changes
Changes in skin with age include:
Loss of elastin and collagen resulting in thinner, sagging, and wrinkled skin.
Decreased subcutaneous fat.
Reduced skin turgor; skin elasticity is often evaluated through hydration status.
Decreased melanin production leading to gray and white hair.
Atrophy of hair follicles may lead to baldness.
Cultural Considerations
Cultural aspects impacting skin health:
Use of head coverings.
Variations in hair texture.
Differences in skin tone and pigmentation.
Urgent Assessment Indicators
Signs that require immediate assessment:
Dehydration: Look for dry skin, chapped lips.
Cyanosis: A bluish color indicating lack of oxygen.
Impaired skin integrity: Check for cuts, abrasions, or pressure injuries.
Subjective Data Collection: Health History Questions
Key areas to investigate:
Risk factors: Family history of skin conditions.
Personal health: Existing conditions affecting skin such as diabetes or vascular diseases.
Medications/allergies: Determine potential impacts on skin health.
Self-examination practices.
Subjective Data for Specific Age Groups
Infants and Children:
Query about the presence of birthmarks or changes in skin color.
Assess for physiologic jaundice, cyanosis, rashes, burns, and bruises.
Consider exposure to contagious skin conditions such as scabies or impetigo.
Ask about any contact with toxic plants and sunscreen usage.
Adolescents:
Inquire about common skin issues like pimples or blackheads.
Assess sunscreen usage to prevent skin damage.
Older Adults:
Ask:
"What changes have you noticed in your skin in the last few years?"
"Is there any delay in wound healing?"
"Any noticeable changes in feet, nails, bunions, or comfort in wearing shoes?"
"Have you had any falls resulting in bruises or trauma?"
"Do you have a history of diabetes or peripheral vascular disease?"
Cultural Sensitivity in Assessments
Case Example:
An Arabic woman coming for a first-time clinic visit: The nurse must consider cultural practices such as the necessity of having a chaperone during medical assessments.
Physical Examination Guidelines
Environment: Ensure a warm room and maintain patient privacy.
Equipment Needed:
Strong direct lighting for inspection.
Gloves to maintain hygiene.
Penlight for detailed examination.
Small centimeter ruler for measurements.
Magnifying glass for closer inspection.
Inspection Guidelines
Key factors to check during inspection:
Skin color, texture, and distribution.
General pigmentation including freckles, moles, and birthmarks.
Note any lesions and describe color changes over the body: pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow).
Assess vascularity, such as bruises and needle marks.
Inspection of Hands and Nails
Factors to assess:
Shape and contour of nails.
Color of the nails and surrounding skin.
Capillary refill time to check circulation.
Health Promotion and Skin Care Education
Promote health self-care:
Teach skin self-examination using the ABCDE rule to identify suspicious lesions:
A - Asymmetry: One half does not match the other half.
B - Border: Irregular, ragged, or blurred edges.
C - Color: Varying from one area to another.
D - Diameter: Larger than 6mm (the size of a pencil eraser).
E - Elevation and Enlargement: A mole that is raised or has gotten larger over time.
Palpation Techniques
Temperature: Check with the dorsal surface of the hand; skin should feel warm with equal temperature bilaterally.
Note that hands and feet may be slightly cooler in a cool environment.
Check for hypothermia/hyperthermia; edema; moisture levels; and signs of diaphoresis;
Assess hydration and skin turgor.
Braden Scale for Predicting Pressure Sore Risk
The Braden Scale evaluates specific rise factors:
Mobility: Ability to change positions.
Friction & Shear: Forces that can cause skin breakdown.
Abnormal Skin Findings: Shapes of Lesions
Varied Shapes:
Annular or Circular
Confluent
Discreet
Gyrate
Grouped
Zosteriform
Polycyclic
Target-shaped
Linear
Primary Skin Lesions
Types of primary skin lesions include:
Nodule: Elevated, solid lesion.
Wheal: Elevated, often itchy area of localized skin edema.
Macule: Flat, discolored lesion, not elevated.
Papule: Small, raised, solid lesion.
Cyst: Closed sac-like structure filled with liquid or semi-solid material.
Pustule: Elevated, pus-filled lesion.
Secondary Skin Lesions
Types of secondary skin lesions include:
Crust: Dried residue of serum, pus, or blood.
Scale: Flaky exfoliation of skin.
Fissure: Linear crack in the skin.
Erosion: Loss of part or all of the epidermis.
Ulcer: Loss of epidermis and part of dermis.
Excoriation: Erosion caused by scratching.
Lichenification: Thickened skin with increased markings due to chronic scratching or rubbing.
Keloid: Hypertrophic scar that extends beyond original boundaries.
Scar: Residual mark left from prior injury or illness.
Atrophic scar: Depressed scar; loss of tissue.
Hemangiomas: Vascular lesions; variations include:
Port Wine Stain: Flat, pink, reddish lesions.
Strawberry Mark: Raised, red lesions seen often in infants.
Cavernous Hemangioma: Larger, deeper vascular lesions.
Telangiectases and Vascular Lesions
Types of telangiectases include:
Spider/Star Angioma: Small, dilated blood vessels with a red spot.
Venous Lake: Blue lesions formed by dilated venules.
Purpuric Lesions: Non-blanching purple spots due to bleeding under the skin, including:
Petechiae: Small red or purple spot caused by bleeding.
Purpura: Larger areas of purplish discoloration.
Trauma-Related Lesions
Skin lesions caused by traumatic injuries or abuse may include:
Contusions: Bruises resulting from blunt trauma.
Common Lesions in Children
Common conditions include:
Diaper dermatitis: Common skin irritation in infants.
Intertrigo: Skin inflammation caused by friction, often in skin folds.
Impetigo: Contagious bacterial skin infection common in children.
Atopic dermatitis (eczema): Chronic skin condition presenting with itchy, inflamed skin.
Measles (rubeola): Viral infection characterized by a distinctive rash.
German measles (rubella): Viral infection with a milder rash.
Chickenpox (varicella): Viral infection known for itchy rashes and blisters.
Common Skin Lesions
Lesions may include:
Primary contact dermatitis: Skin reaction following direct contact with an irritant or allergen.
Allergic drug reaction: Skin reaction due to medication allergies.
Tinea corporis: Fungal infection (ringworm) affecting the body.
Tinea pedis: Fungal infection (athlete's foot) affecting the feet.
Psoriasis: Chronic skin disease characterized by red, scaly patches.
Tinea versicolor: Fungal condition causing discolored patches on the skin.
Labial herpes simplex: Cold sores caused by herpes simplex virus.
Herpes zoster: Shingles caused by reactivation of varicella zoster virus.
Erythema migrans: Rash associated with Lyme disease, often a target-shaped lesion.
Malignant Skin Lesions
Types of skin cancer include:
Basal Cell Carcinoma: Most common type of skin cancer, often arising from sun exposure.
Squamous Cell Carcinoma: Second most common; also related to UV radiation.
Malignant Melanoma: Most dangerous type; rapidly spreading skin cancer.
Metastatic Malignant Melanoma: Melanoma that has spread to other parts of the body.
AIDS-Associated Skin Lesions
Skin conditions linked with AIDS include:
Kaposi’s Sarcoma: A vascular tumor considered an AIDS-defining illness, occurring in HIV-infected individuals at any stage of the infection.
Abnormal Conditions of the Hair
Common conditions affecting hair include:
Seborrheic dermatitis: Scalp condition, often referred to as cradle cap in infants.
Tinea capitis: Scalp ringworm infection leading to hair loss.
Alopecia: Hair loss due to various causes.
Furuncle: A painful pus-filled bump (boil) around hair follicles.
Abscess: Collection of pus in the tissue.
Trichotillomania: Compulsive hair pulling leading to hair loss.
Pediculosis capitis: Infestation of the scalp by lice.
Folliculitis: Inflammation of hair follicles.
Hirsutism: Excessive hair growth in women in areas where men typically grow hair.
Abnormal Conditions of the Nails
Abnormal conditions affecting nails may include:
Scabies: Parasitic infestation leading to itchiness and skin irritation.
Splinter hemorrhages: Small, dark lines under the nails, often indicative of trauma or systemic issues.
Pitting: Indentation of the nails, commonly associated with psoriasis. I