1. Chapter 12
Skin, Hair, and Nails

2. 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

3. SKIN

4. 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

5. 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

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

7. 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

8. 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

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

10. Freckles, flat nevi, measles
Macule

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

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

13. Mosquito bite, allergic reaction
Wheal

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

15. Encapsulated fluid-filled cavity…sebaceous cyst

16. Turbid fluid…pus, elevated…impetigo, acne
Pustule

17. 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

18. Fissure:cracks
(athletes foot,etc)
Fissure

19. Ulcer

20. Scar

21. Keloid

22. 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

23. 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

24. HOW DOES MELANOMA BEGIN?

25. HAIR

26. 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

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

28. NAILS

29. Structure of Nails

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

31. 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

32. Onychomycosis
Fungal infection of the nail
Nails: Infection 32

33. Health history

34. 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

35. 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

36. 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

37. 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

38. 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…

39. 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).

40. 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

41. 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

42. 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

43. 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

44. 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

45. The end!