Integumentary Assessment Skin, Hair, and Nails Georgia Baptist College of Nursing Of Mercer University Mary M. Hudgins, RN, MSN Instructor
What Are We Talking About? Structure and Function Subjective Data Health History Questions Objective Data The Physical Exam Abnormal Findings
Structure and Function Skin – _________ Layers Epidermis ▫ Stratum Germinativum (basal skin layer) –Forms _____ ______ _______ ▫ Stratum Corneum (horny cell layer) –Constantly being _______ ▫ Derivation of skin __________ –Melanin –Carotene –Vascular bed
Skin Layers Continued…. Dermis Connective tissue (__________) __________ tissue Subcutaneous Layer
Epidermal Appendages Hair __________ hair ____________ hair Sebaceous Glands Sweat glands __________ glands ___________ glands Nails
Functions of the Skin Covers the _______ ________ of body Protects body from trauma and ________ Prevents the loss of ________ and ______________ Senses __________, pain, ________, pressure
Functions of the Skin Regulates body _______________ through _______ ____________ and evaporation Synthesizes Vitamin ______ Promotes wound ___________ – _____ _________
Relationship of Skin, Hair, and Nails with Body Systems Respiratory Cardiovascular Gastrointestinal Neurological Endocrine Immune
Chief Complaints Rash or skin _________ Changes in skin _________ Itching (________) Changes in Hair Changes in Nail
Subjective Data Health History Questions Hx of skin disease? Any known _________? Family History? Birthmarks or ___________? Change in skin ______ or _________? Generalized or localized? Change in ______? ________that does not heal?
Health History Cont. Excessive dryness or moisture? Itching? Excessive ________? Rash or __________? _____________
Health History: Hair Loss or gain? Changes in _______ or appearance? Associated with other symptoms? Unusual ___________? Serious illness?
Health History: Nails Change in nails? What is ________ condition? Do you ______ or ________ nails? __________ nails, tips, chemicals
Health History Environmental/Occupational _________? _______ exposure? Recent __________ __________? Exposure to plants/_________ Self-care
Objective Data The Physical Exam Equipment Strong Direct Lighting Small Centimeter Ruler Penlight Gloves Magnifying Glass
Physical Exam Inspection General to ____________ Drape Begin with exposed areas Compare ▫ __________ ____________ areas ▫ _________ exposed/non-exposed areas Cleanliness
Palpation ___________ areas first Compare ___________ for general differences/ Moisture Back of hand (dorsa)
Skin Assessment Color General Pigmentation Widespread __________ Change –Pallor –__________ –Cyanosis –___________
Skin Assessment Inspect and Palpate Temperature ___________ ____________ Moisture ___________ ______________
Skin Assessment Inspect and Palpate Texture ___________ Edema Mobility and __________ Vascularity or _____________
Skin Lesions Inspect and Palpate Color _________ Pattern or ________ Size ________ and distribution Exudate
Promoting Health and Self-Care Teach skin self-examination ABCDE rule – Abnormal Characteristics A______________ B_______ ___________ C________ ____________ D__________ ____________ E_________ and _____________
Hair Assessment Inspect and Palpate Color ________ Distribution _________
Nail Assessment Inspect and Palpate Shape and contour ______ ________ Consistency Color ________ ________
Special Assessment Considerations Infants Adolescents Pregnant Female Aging Adults Cultural/Ethnicity
Abnormal Findings Shapes/Configurations of Lesions Annular or circular Confluent Discrete Grouped Gyrate Target or Iris Linear Polycyclic Zosteriform
Confluent
Grouped Lesions
Abnormal Findings Primary Skin Lesions Macule Papule Patch Plaque Nodule Wheal Tumor
Papule Wheal
Abnormal Findings Primary Skin Lesions Urticaria Vesicle Cyst Bulla Pustule
Vesicle Pustule
Vascular Lesions Purpura Petechiae
Abnormal Skin Findings Secondary Lesions Crust Scale Fissure Erosion Ulcer Excoriation Scar Atrophic Scar Lichenification Keloid
Ulcer Keloid
Malignant Skin Lesions ___________ Cell Carcinoma _________ cell carcinoma ________________ Melanoma
Abnormal Conditions of Hair _________ dermatitis Alopecia Pediculosis capitis Folliculitis __________
Abnormal Conditions of the Nails ________ Lines __________ Infection Clubbing
Clubbing
Documentation of Findings: Lesions - Size- Tenderness - _____- Blanching or - Exudate- _________of - Shape vascular lesion - _______- Pattern ___________, distribution