Chapter 12 Skin, Hair, and Nails

OBJECTIVES 1.Discuss the anatomy and physiology of the targeted areas discussed in class 2.Conduct a history related to the Skin, Hair, Nails system. 3.Be able to identify changes in the older adult for skin, hair, and nails. 4. Identify risk factors for melanoma, basal and squamous cell cancer 5.Recognize and understand findings that deviate from expected findings for abnormals: basal cell cancer, Squamous Cell Carcinoma, Malignant Melanoma, tinea pedis, (Define terms Alopecia, Hirsutism , vitiligo only) 6.Describe how to do a skin, hair, & nail assessment with correct terminology 7.Identify lesions common to healthy older adults 8.Identify primary and secondary lesions: macule, papule, wheal, nodule, tumor, vesicle, pustule, cyst, keloid, scar, fissure ulcer

SKIN

Structure: Skin Think of skin as body’s largest organ system Covers 20 square feet of surface area in adults Skin is the sentry that guards body Skin has two layers Epidermis: outer highly differentiated layer Basal cell layer forms new skin cells Outer horny cell layer of dead keratinized cells Dermis: inner supportive layer Connective tissue or collagen Elastic tissue Beneath these layers is a subcutaneous layer of adipose tissue Keratin: protein that is the major tough, fibrous ingredient in epidermis

Skin is waterproof, protective, and adaptive Skin Function Protection from environment Prevents penetration Perception Temperature regulation Identification Communication Wound repair Absorption and excretion Production of vitamin D Skin is waterproof, protective, and adaptive

Leathery skin What do we tell this person? SHE IS IN BIG TROUBLE!!!

The Aging Adult Elasticity Sweat and sebaceous glands Senile purpura Loses elasticity; skin folds and sags Sweat and sebaceous glands Decrease in number and function, leaving skin dry Senile purpura Discoloration due to increasing capillary fragility Skin breakdown due to multiple factors Cell replacement is slower and wound healing is delayed Hair matrix Functioning melanocytes decrease, leading to gray fine hair Nails Grow more slowly Toenails become thicker, brittle, hard, yellow Cherry angioma, senile lentigines, seborrheic keratosis, senile purpura, skin tags

Genetic attributes of dark-skinned individuals afford protection against skin cancer due to melanin Increased likelihood of skin cancer in Whites than in Black and Hispanic populations Most important environmental risk factor for skin cancer is exposure to ultraviolet (UV) radiation both from sun and tanning sources Increased risk for melanoma related to increased number of sunburns during one’s lifetime Certain skin presentations associated with different ethnic groups Culture and Genetics

Primary Skin Lesions Macules Tumors Papules Urticaria (hives) Patches Plaques Nodules Wheals Tumors Urticaria (hives) Vesicles Cysts Bullas Pustules Primary Skin Lesions

Freckles, flat nevi, measles Macule

Papule: < 1 cm…Elevated mole (nevis), wart…firm

Nodule VS TUMOR Nodule: > 1 cm…Fibroma, intradermal nevi, Tumor: > a few cm… lipoma, hemangioma… can be benign or malignant Nodule VS TUMOR

Mosquito bite, allergic reaction Wheal

Chicken pox (early varicella), herpes zoster(shingles), contact dermatitis Vesicle/Bulla

Encapsulated fluid-filled cavity…sebaceous cyst

Turbid fluid…pus, elevated…impetigo, acne Pustule

Secondary Skin Lesions Break in continuity of skin surface Fissures Erosions Ulcers Excoriations Scars Atrophic scars Lichenifications Keloids Debris on skin surface Crusts Scales Secondary Skin Lesions

Fissure:cracks (athletes foot,etc) Fissure

Ulcer

Scar

Keloid

Malignant SKIN LESIONS Basal cell carcinoma Squamous cell carcinoma Most common form of skin cancer Second most common skin cancer Basal cell carcinoma begins in the basal cells. Deepest layer of the epidermis, known as the basal layer, contains basal cells. Starts as papule. Develops rounded borders w central red ulcer or large open pore. Most commonly affects areas of the body exposed to environmental factors including the face, ears, neck, scalp, shoulders and back. Squamous cell carcinoma affects the squamous cells---flat cells found in and just under the outer most layer of the epidermis known as the stratum corneum. Develops central ulcer w surrounding erythema… commonly found on the face, head, ears, lips, back of hands and neck, can also occur in scars and skin ulcers in other parts of the body, as well as in the genital area. Basal less aggressive than squamous But neither spreads easily to other parts of the body Treatable by excision usually Malignant SKIN LESIONS

Skin: Malignant/CUTANEOUS NeoplasM (Cont.) Malignant melanoma Lethal form of skin cancer that develops from melanocytes Flat mole, uneven edges, shape Color: black, brown, or more than 1 color Can be a new spot or from existing nevi CAN SPREAD to organs/bones Usually on upper back of men/women; but also on legs of women (maybe because of sun exposure?) E: Elevation/enlargement PROMOTE SELF CARE AND EXAMINATION!!!! 23

HOW DOES MELANOMA BEGIN? www.youtube.com/watch?v=G39rH6P6K9c

HAIR

Structure: Epidermal Appendages Hair Sebaceous glands Sweat glands: important for fluid balance and thermoregulation Eccrine glands Apocrine glands Hair: these are threads of keratin. Have 2 types of hair…vellus (fine) and terminal (courser) Structure: Epidermal Appendages

Hirsutism Growth of terminal hair in women in the male distribution pattern on the face, body, and pubic areas

NAILS

Structure of Nails

Aging nails… Normal ridging in aging process Yellow color: with psoriasis(red inflamed lesions), fungal infections, respiratory disease Aging nails…

The nail base angle should measure: 160 degrees The nail base angle should measure: 160 degrees. In clubbing the angle > or exceeds 180 degrees. Hypoxemia present?...associated with a variety of respiratory and cardiovascular diseases, or cirrhosis, colitis, and thyroid disease Clubbing of nails

Onychomycosis Fungal infection of the nail Nails: Infection 32

Health history

Subjective Data Health History Questions Past history of skin disease, allergies, hives, psoriasis, or eczema? Change in pigmentation or color, size, shape, tenderness? Excessive dryness or moisture? Skin itching? Excessive bruising? Rash or lesions? Medications: prescription and over-the-counter? Hair loss? Change in nails’ shape, color, or brittleness? Environmental or occupational hazards? Self-care behaviors? WHAT is it? WHEN did it occur…did you first notice it? WHERE is it? HOW did it happen?.... WHY is this happening…because of other medical, environmental, social, etc. problems? Edition Change: Incidence of melanoma in Whites is noted to be 20 times higher than in Blacks and 4 times higher than in Hispanics. Edition Change: Skin conditions that are noted to be specific to Black patients are as follows: Keloids Pigmentary disorders Pseudofolliculitis Melasma Subjective Data Health History Questions

Health History Questions cont’d For the Aging Adults… What changes have you noticed in your skin in past few years? Any delay in wound healing? Any change in feet: toenails, bunions, wearing shoes? Falling: bruises, trauma? History of diabetes or peripheral vascular disease? Do you do anything to care for your skin? Edition change: Incidence of melanoma in Whites is noted to be 20 times higher than in Blacks and 4 times higher than in Hispanics. Edition change: Skin conditions that are noted to be specific to Black patients are as follows: Keloids Pigmentary disorders Pseudofolliculitis Melasma Health History Questions cont’d

Objective Data: Physical examination and findings Preparation Consciously attend to skin characteristics; the danger is one of omission Equipment needed: tape measure, pen light, gloves Objective Data: Physical examination and findings

Complete Physical Examination thoughts… Skin assessment integrated throughout examination Scrutinize the outer skin surface first before you concentrate on underlying structures Separate areas with skinfolds such as under large breasts, obese abdomen, and groin, and inspect them thoroughly These areas are dark, warm, and moist and provide perfect conditions for irritation or infection Always inspect feet, toenails, and between toes

Individuals may seek health care for skin problems and assessment focused on skin alone Assess skin as one entity; getting overall impression helps reveal distribution patterns Inspect lesions carefully With a rash, check all areas of body as you cannot rely on the history that rash is in only one location Skills used are inspection and palpation because some skin changes have accompanying signs that can be felt Thoughts cont’d…

Inspection and Palpation: Skin Color General pigmentation, freckles, moles, birthmarks Widespread color change Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow) Note if color change transient or due to pathology Vascularity or bruising: Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse Needle marks or tracks from intravenous injection of street drugs may be visible on antecubital fossae, forearms, or on any available vein Temperature Use backs of hands to palpate person Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status Hands and feet may be slightly cooler in a cool environment Hypothermia Hyperthermia Katie Beezhold: Raynaud Disease (peripheral arterial insufficiency of the small arteries and arterioles; cause unknown. Vasomotor response to cold and emotion. First white (pallor), then blue (cyanosis), then red (hyperemia as blood flow returns).

Inspection and Palpation: Skin (Cont.) Moisture Diaphoresis Dehydration Texture Turgor Lesions: if any are present, note the following: Color Elevation Pattern or shape Size Location and distribution on body Any exudate: note color and odor Tatoo’s too! Tatoo’s, cherry angioma’s, seborrhea keritosis

Inspection and Palpation: Hair Color Due to melanin production Texture Characteristics range from fine to thick to curly to straight and may be affected by use of hair care products Distribution Scalp, face, body?...absence of, thick/thin Lesions Identification by looking at scalp and dividing hair into sections Inspection and Palpation: Hair

Inspection Palpation: Nails Shape and contour: Profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees Texture: smooth, ridging, brittle, splitting Thickness: should be uniform (check toes) Adherence: firm, not spongy Color: usually pink, dark skinned people may have brown/black linear bands Capillary refill: Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation Color return is normally instant. Sluggish color return takes longer than 1 or 2 secs

The nurse is assessing a patient who has been admitted for liver failure. What finding would the nurse expect? Cyanosis Erythema Pallor Jaundice The correct answer is 4. Jaundice is a common hallmark of cirrhosis, which is one complication of liver failure. Answers 1, 2, and 3 have no common connection to liver failure. Question

Summary Checklist: Skin, Hair, and Nails Inspection of the skin, hair, and nails Color and pigmentation Texture and distribution Shape, contour, and consistency ( nail thickness, adherence, texture) Palpation of the skin, hair, and nails Temperature and texture, distribution Edema, mobility, and turgor, nail refill Note presence of lesions Shape, configuration, and distribution Teach self-examination Health promotion Summary Checklist: Skin, Hair, and Nails

The end!