[PPT]Weber: Health Assessment in Nursing - Lippincott...

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WeberHealth Assessment in Nursing

Chapter 14: Assessing Skin, Hair, and Nails


Structure and Function of Skin

• The skin is a physical barrier that protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, and dehydration.

• Vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.


Skin, Hair and Nails• Skin- epidermis, dermis, subcutaneous

layers• Hair- vellus, terminal• Nails- hard, transparent plates of

keratinized epidermal cells


Question

Is the following statement True or False?

Sebum has some fungicidal and bactericidal effects.


Answer

True.Sebum has some fungicidal and bactericidal effects.


Question

Is the following statement True or False?Asians and Native Americans have strong body odor.


Answer

False.Asians and Native Americans have mild to no body odor because of decreased sweat production. Caucasians and African Americans tend to have a strong body odor.


Skin Cancer• Most common of cancers• Three types: melanoma, basal cell

carcinoma, squamous cell carcinoma• Asians are less susceptible


Risk Factors of Skin Cancer• Sun exposure• Nonsolar sources of ultraviolet radiation• Medical therapies• Family history and genetic susceptibility• Moles• Pigmentation irregularities• Fair skin that burns and freckles easily; light hair• Age


Risk Factors of Skin Cancer (Cont’d)• Male gender• Chemical exposure• Human papillomavirus• Xerodrem pigmentosum• Long-term skin inflammation or injury• Alcohol intake; smoking• Inadequate niacin in diet


Risk Reduction in Skin Cancer• Reduce skin exposure• Always use sunscreen when sun exposure is

anticipated• Wear long-sleeve shirts and wide-brimmed hats• Avoid sunburns• Understand the link between sun exposure and skin

cancer and the accumulating effects of sun exposure on developing cancers

• Have annual skin cancer screenings


Risk Reduction in Skin Cancer• Ensure diet is adequate in vitamin B3

• Examine the skin for suspected lesions– Use the ABCDE mnemonic to assess suspicious

lesions:– Asymmetry– Border– Color– Diameter– Elevation


Question

Which skin disorder may be caused by exposure to the sun?a. Acneb. Cancer c. Vitiligod. Warts


Answer

b. Cancer.Rationale: Skin cancer may be caused by exposure to the sun. Acne, vitiligo, and warts are not caused by sun exposure.


Cultural Variations in Skin Cancer• Lowest rates: Asians • Highest rates: white Australians• Most susceptible are people with pale

white, freckled skin and red hair


Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS• Assess for hospital-acquired MRSA risk factors:

– Having an invasive medical device– Residing in a long-term care facility


Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (CONT.)• Assess for community-acquired MRSA risk factors:

– Participating in contact sports– Sharing personal items such as towels or razors– Suppression of the immune system function (e.g.

HIV, cancer, or chemotherapy)– Residing in unsanitary or crowded living

conditions (dormitories or military barracks)


Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (CONT.)• Working in the health-care industry• Receiving antibiotics within the past 3 to 6 months• Young or advanced age• Men having sex with men


Measures to Reduce Risk Factors• 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.


Nursing History: Present Health Concern• Body odor problems• Skin problems (rashes, lesions, dryness, oiliness,

drainage, bruising, swelling, pigmentation)• Changes in lesion appearance• Feeling changes (pain, pressure, itch, tingling)• Hair loss or changes• Nail changes


Nursing History (cont.)• Personal health history• Family history• Lifestyle and health practices

• Exposure to sun or chemicals• Daily care of skin, hairs, nails• Usual diet and exercise patterns


Client Preparation• Ask the client to remove all clothing

and jewelry• Have the client sit comfortably• Ensure privacy• Maintain comfortable room

temperature


Equipment• Gloves• Examination light and penlight• Magnifying glass• Centimeter ruler• Wood’s light• Examination gown or drape


Skin Assessment: Inspection• Note any distinctive odor• Generalized color variations• Skin breakdown• Primary, secondary, or vascular lesions


Skin Assessment: Palpation• Lesions• Texture• Temperature and moisture• Thickness of skin• Mobility and turgor• Edema


Pressure Ulcer Risk Factors• Perception• Mobility• Moisture• Nutrition• Friction or shear against surfaces• Tissue tolerance decreased


Pressure Ulcer Risk Reduction• Inspect the skin at least daily and more often if at greater

risk using risk assessment tool (such as Braden Scale or PUSH tool) and keep flow chart to document.

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

• For dry skin: use moisturizers; avoid low humidity and cold air.

• Avoid vigorous massage.


Pressure Ulcer Reduction (cont.)• Use careful positioning, turning, and transferring

techniques to avoid shear and friction or prolonged pressure on any point.

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

• Refer incontinence condition to primary care provider.• Use incontinence skin cleansing methods as needed:

frequency and methods of cleaning, avoiding dryness with protective barrier products.


Scalp and Hair• Inspection and palpation

– General color and condition, cleanliness, dryness or oiliness, parasites, and lesions

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


Nail Assessment• Nails

– Inspection: Nail grooming and cleanliness, nail color and markings, shape of nails,

– Palpation: Texture, assess texture and consistency, capillary refill


Nails Risk Factors• Nails in moist environment, especially walking in damp

public locales or continuously wearing closed shoes; excessive perspiration.

• Nail injury, trauma, or irritation • Immune system disorders such as diabetes mellitus and

AIDS or on immunosuppressive medications.• Skin conditions such as psoriasis or lichen.• Some trades or professions • Contagion from one digit to another or one person to

another.• Possibly family predisposition.


Nails Risk Reduction Tips• Wear leather shoes except for sports.• Avoid wearing closed shoes all the time.• Wear socks that wick away moisture.• Avoid going barefoot in damp public areas.• Avoid too much perspiration or water (wear gloves for

hands).• Avoid trauma to nails.• Avoid unsanitary or unsafe nail care practices• If treatment is started, do not stop until recovery is

complete.


Physical Assessment (cont.)• Capillary refill• Hair color and texture

– Individuals of black American descent often have very dry scalps and dry, fragile hair.


Self-Assessment Skin, Hair, Nails• Refer to Box 14.1 Self Assessment: How to Examine

Your Own Skin


Normal and Abnormal Findings• Share outcomes of assessment with peers


Pressure Ulcer Stages• Stage One• Stage Two• Stage Three• Stage Four• Unstagable


Primary Skin Lesions• Macule and Patch• Papule and Plaque• Nodule and Tumor• Vesicle and Bulla• Wheal• Pustule• Cyst


Secondary Skin Lesions• Erosion• Ulcer• Sacr• Fissure


Vascular Skin Lesions• Petechia• Ecchymosis• Hematoma• Cherry Angioma• Spider Angioma• Telangiectasis


Common Nail Disorders• Longitudinal ridging• Half and half nails• Pitting• Koilonychia• Yellow nail syndrome• Paronychia


Common Changes Aging• Skin

– Pale– Skin lesions– Dry– Loses turgor

• Hair: Thinner• Nails: Thickened, yellow, brittle


Validating and Documenting Findings• Health promotion diagnoses• Risk diagnoses• Actual diagnoses• Collaborative problems• Medical problems

[PPT]Weber: Health Assessment in Nursing - Lippincott...

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