1. CHAPTER 12 SKIN, HAIR, AND NAILS

2. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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 2

3. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. SKIN 3

4. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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 4

5. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. SKIN FUNCTION Skin is waterproof, protective, and adaptive  Protection from environment  Prevents penetration  Perception  Temperature regulation  Identification  Communication  Wound repair  Absorption and excretion  Production of vitamin D 5

6. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. LEATHERY SKIN What do we tell this person?

7. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. THE AGING ADULT 7 Elasticity  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

8. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. CULTURE AND GENETICS 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 8

9. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. Macules Papules Patches Plaques Nodules Wheals Tumors Urticaria (hives) Vesicles Cysts Bullas Pustules 9 PRIMARY SKIN LESIONS

10. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. MACULE 10

11. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. PAPULE 11

12. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. NODULE 12

13. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. WHEAL 13

14. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. VESICLE/BULLA 14

15. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. CYST 15

16. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. PUSTULE 16

17. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. Debris on skin surface  Crusts  Scales Break in continuity of skin surface  Fissures  Erosions  Ulcers  Excoriations  Scars  Atrophic scars  Lichenifications  Keloids 17 SECONDARY SKIN LESIONS

18. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. FISSURE 18 Fissure:cracks (athletes foot,etc)

19. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. ULCER 19

20. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. SCAR 20

21. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. KELOID 21

22. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. MALIGNANT SKIN LESIONS 22 Basal cell carcinoma Squamous cell carcinoma Most common form of skin cancer Second most common skin cancer 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 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.

23. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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 23

24. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. https://www.youtube.com/watch ?v=0LWkxM6xebY HOW DOES MELANOMA BEGIN?

25. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. HAIR 25

26. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. STRUCTURE: EPIDERMAL APPENDAGES  Hair  Sebaceous glands  Sweat glands: important for fluid balance and thermoregulation  Eccrine glands  Apocrine glands 26

27. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. HIRSUTISM  Growth of terminal hair in women in the male distribution pattern on the face, body, and pubic areas 27

28. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. NAILS 28

29. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. STRUCTURE OF NAILS 29

30. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 30 Normal ridging in aging process Yellow color: with psoriasis(red inflamed lesions), fungal infections, respiratory disease

31. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. CLUBBING OF NAILS The nail base angle should measure: 160 degrees. In clubbing the angle > or exceeds 180 degrees.

32. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. NAILS: INFECTION Onychomycosis  Fungal infection of the nail 32

33. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. HEALTH HISTORY 33

34. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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? Pruritus or 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? 34

35. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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? 35

36. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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 36

37. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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 37

38. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. THOUGHTS CONT’D… 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 38

39. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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 39

40. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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! 40

41. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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 41

42. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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 Cleanliness 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 42

43. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. QUESTION The nurse is assessing a patient who has been admitted for liver failure. What finding would the nurse expect? 1.Cyanosis 2.Flushing 3.Rubor 4.Jaundice 43

44. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 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  Edema, mobility, and turgor Note presence of lesions  Shape, configuration, and distribution Teach self-examination  Health promotion 44

45. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 45